在宅醫療的新篇章：高價值基礎支付的在宅住院模式

A new opportunity for home-based medical care: the value-based hospital-at-home payment model

隨著人口老化，急症住院需求增加，然而醫院量能成長有限，以在宅住院模式來補足與強化在宅醫療體系成為重要議題；另一方面，健康體系支付改革近年來逐步朝向「高價值照護」（high-value care）倡議與邁進，提出照護模式除了需有臨床療效外，應以病人為中心，並在合適的成本下，提供全人整合醫療照護。本文從價值基礎照護模式的角度，先討論各國在宅住院（Hospital at Home, HaH）的支付設計是否符合高價值基礎，再針對台灣健保在宅急症照護（即在宅住院）試辦計畫進行解析。本文並提出台灣在宅住院模式面臨的六項基本挑戰，包括1.在宅急症照護的成本未知，2.在宅住院可能具有非醫療的效益但難以測量，3.效益或價值的測量可能有地域差異，4.包裹式支付設計尚未能涵納必要的跨專業人員，5.在宅住院的資訊系統整合的挑戰，以及6.與長照系統整合不易。最後，本文建議未來針對台灣的既有健康體系的特色來調整在宅住院模式，例如與長照系統整合，或是擴大更多醫事人員的整合與團隊組成，擴大導入資訊科技等，使在宅醫療朝高價值的全人照護模式邁進。

The aging of populations is expected to drive an increased demand for acute hospitalization. For hospitals facing limited resource growth and capacity, hospitalization can be substituted with a hospital-at-home (HaH) model. Recent reforms to health-care systems have focused on designing value-based care models. High-value care models should be cost-effective, patient-centered, and integrated and should ensure intervention efficacy. The current review introduces HaH models in different countries and outlines their value-based payment designs. These models are then compared with the HaH model under Taiwan’s National Health Insurance scheme (the ''Acute Care at Home'' model). The HaH model in Taiwan is subject to six key challenges: 1) uncertainty regarding actual HaH care costs, 2) difficulty in quantifying nonclinical efficacy, 3) geographic variation in care effectiveness, 4) incomplete integration of essential professions within the current bundled payment design, 5) complexities in information system integration, and 6) challenges in integrating HaH with long-term care services. To ensure high-value, holistic care under Taiwan’s HaH model, health-care providers can leverage existing home-based care infrastructure. HaH care should be integrated with long-term care, care teams should be expanded to encompass a wider range of professions, and robust information technology solutions should be implemented.