醫院退出市場因素之分析

An empirical analysis of exits from the hospital market

目標：本文主要在探討台灣實施全民健康保險後，影響醫院退出市場之因素，並瞭解醫院總額預算支付制度實施前後，影響醫院退出市場的因素是否有所不同。方法：利用全民健康保險研究資料庫，以1998年至2012年與健保署簽有特約之區域醫院及地區醫院為觀察對象，結束健保特約作為退出市場之代理變數，分為實施醫院總額預算制度前（1998-2002）及實施後（2003-2012）兩組樣本，利用Cox比例危險模型進行分析。結果：醫院的特性，如院齡、門診診次、住院診次，以及地區特性，如上年度進入率、最小有效規模、老年人口比例、家戶可支配所得、人口數等，為實施醫院總額預算制度之前影響醫院存活之重要因素。而在實施醫院總額預算制度後，地區醫院之權屬別、門診規模賀芬達指數、平均每公頃土地現值、門診與住院診次成長率，則成為影響醫院是否退出市場的主要因素。結論：台灣醫院市場在實施總額預算後，市場競爭與醫院權屬別成為影響醫院退出的重要因素，而醫療院所產業似乎也更朝向兩極化的不平衡發展。

Objectives: Using the termination of the NHI contracts as a proxy for exit from the hospital market, this study investigated the factors that affect exits from the hospital industry, and compared these factors before and after implementation of the Global Budget Scheme (GBS) in July 2002. Methods: The data, including metropolitan and local community hospitals, were extracted from the NHI Research Database from 1998-2012. We divided samples into two parts (before the GBS [1998-2002] and after the GBS [2003-2012]), and used a Cox proportional hazards regression model to conduct our analysis. Results: The factors that affect exits from the hospital industry include the following: (1) characteristics of hospitals, such as the duration of hospitals, outpatient visit volume, and admission volume; and (2) characteristics of areas, such as the rate of entry last year, minimum efficient scale, proportion of aged population, disposable income per household, and population. After implementation of the GBS, ownership of the local community hospital, the Herfindahl-Hirschman index, the average current land value per hectare, the number of outpatient visits, and the admission growth rate became significant factors of exit from the hospital industry. Conclusions: After the implementation of the GBS, market competition and ownership of hospitals affect the exiting of hospitals. There is a more unbalanced development among large- and small-scale hospitals.