運用預控圖監控診斷關係群費用之研究－－以部分髖關節置換術為例

The Utilization of Pre-control Charts in Monitoring the Procedural Expenditure of Taiwanese

台灣近年人口老化嚴重，也造成髖關節盛行率節節上升，加上台灣於2010年實施診斷關係群支付制度後，部分落入診斷關係群之疾病群組給付方式改採定額給付，造成醫院財源有很大的衝擊，而部分髖關節置換術即是其中一例。監控醫療費用最常使用的工具是管制圖，但學習管制圖需要複雜數學理解程序與電腦運算能力，這對線上基層人員較為困難。故本研究提出使用預控圖進行費用監控，由於預控圖之呈現方式與健保給付上下限規定剛好吻合，在判斷醫療費用盈虧上辨識容易。本研究運用健保資料庫計算不同年齡層部分髖關節之同儕標準值，做為管制圖及預控圖中心線，再以某區域醫院實際資料來說明管制圖與預控圖之使用差異。最後研究結果呈現，當費用變異過大時，管制圖上下限將過寬，不若預控圖以健保局規定做為上下限更能突顯實務上之需要。

In recent years, the aging population in Taiwan resulted in a significant increase in the prevalence of hip orthopaedic surgeries. Since the diagnosis related groups payment system was implemented in Taiwan in 2010, the new system calculates the medical expenditure reimbursement for the diagnosis related groups as a fixed rate subsidy. If not managed properly, such fixed rate subsidy can make a significant impact on hospitals' revenues, where partial hip arthroplasty is an example of those expensive procedures. Therefore, to effectively control medical expenditures has become an important task for the hospitals. Using control charts is one of the most common tools in evaluating hospital spending. However, in learning to utilize the control charts, one must have adequate knowledge in computer skills as well as some complex mathematics. These requirements are hard to come by among the entry-level medical care personnel. Therefore, in this study we propose a more effective method in monitoring medical expenditures using the so called pre-control charts. One can more easily identify medical deficits and profits from the pre-control charts because the chart has boundaries coinciding with the upper and lower limits of the national health insurance subsidy. Our study has analyzed some data gathered from the national health care database in determining the peer standards among different patient age groups, to be used as the center line in the pre-control charts. The results of the analysis indicate that whenever expenditure deviation increases, it would cause a broadening of the pre-control chart's boundary conditions. Therefore, it is more obvious and practical to use the pre-control chart as an expenditure monitoring system, in which the national health care limits can be set to correlate with the cart's boundary conditions. Finally, the differences between the pre-control chart and control chart was further demonstrated with factual data gathered from a regional hospital.