台灣導入診斷關聯群對醫療利用之影響－－以內科系心導管診斷及治療為例

Implementing Tw-DRGs on Diagnostic and Therapeutic Cardiac Catheterization and Impact on Medical Utilization

目的：探討台灣住院診斷關聯群（Diagnosis Related Groups，DRGs）對心導管診斷及治療的影響，包含醫療費用分佈、住院日、醫療費用、支付費用、就醫診斷數在診斷關聯群（DRGs）實施前後改變及不同層級醫院之變異情形。方法：採回溯性研究，以2009年及2010年健保資料庫為資料來源，利用健保網路醫療服務系統產生DRGs碼來收取資料，統計分析以描述性統計分析及醫療費用落點分布，推論性統計使用t-test及Kruskal-Wallis test分析指標之變化。結果：DRGs實施後，實際醫療費用介於下限臨界點至支付定額之間案件上升，實際醫療費用低於下限臨界點、實際醫療費用介於支付定額到上限臨界點及實際醫療費用高於上限臨界點案件下降；醫學中心實際醫療費用介於下限臨界點至支付定額之間案件數呈現下降，而地區醫院則呈現上升，且成長近9成；另，醫學中心在實際醫療費用高於上限臨界點案件數上升。在實施後平均住院日及平均醫療費用有下降但無統計上顯著差異，唯DRG124心導管有複雜診斷的醫療費用顯著性下降；診斷數實施前後無統計上顯著差異，唯DRG125心導管無複雜診斷在實施後診斷數有顯著性上升；正收益差在實施後都顯著性上升。不同層級醫院指標變化，在平均住院日及實際醫療費用均以地區醫院最少，平均正收益差以地區醫院最高，平均支付費用三個層級有顯著性差異，以醫學中心最高、地區醫院最低。結論：導入DRG心導管診斷及治療，以健保支付費用與醫院實際發生費用做比較，呈現整體負收益差案件減少、正收益差的件數增加，對於層級別影響以地區醫院正收益差的比率最高，醫學中心負收益差件數有增加傾向。本研究係以次級資料進行分析，建議未來研究者可利用醫院實際精確資料計算個別醫院病例組合，來反應疾病的風險性及複雜度提升健保DRGs案件支付的合理性。

Objective: The impact of Tw-DRGs on diagnostic and therapeutic cardiac catheterization was determined, including the cost distribution, length of hospital stay, number of diagnoses with pre- and post-implementation changes, and variation between hospitals.Methods: This was a retrospective study. The data sources were the 2009 and 2010 NHI Research Databases and the NHI medical web service was used to generate diagnosis-related group codes. Data fi les and medical cost distributions were analyzed with descriptive statistics, and the impact on medical utilization after implementing Tw-DRGs were analyzed with inferential statistics (t-test and Kruskal- Wallis test). Results: Post-implementation DRGs, the actual cost between the lower critical point to the payment case number was increased; the actual cost below the lower critical point, the actual cost between payment to the upper critical point, and the actual cost above the upper critical point of the case number was decreased.The actual cost between the lower critical point to the payment of the case number decreased. The number of cases in district hospitals, however, increased approximately 90%; the medical center with the actual cost above the upper critical point increased. After implementation, the average length of stay and cost decreased, but did not reach a statistically signifi cant difference. Only DRG124 catheterization with complex diagnosis implementation signifi cantly reduced the cost. There was no significant difference in the number of diagnoses before and after implementation; only the DRG125 catheterization without a complex diagnosis wassignifi cantly elevated.A positive difference in revenue was signifi cantly enhanced after implementation. The indicators for different levels of hospitals changed; district hospitals had the lowest average number of hospitalization days and actual costs. District hospitals also had the highest average positive difference in revenue. Medical centers had the highest average payment and district hospitals had the lowest; there were signifi cant differences between the three levels of hospitals. Conclusions: Implementation of Tw-DRGs and comparing payments and actual costs showed that the overall negative difference in revenue cases decreased and the positive difference in revenue cases increased. The impact of different levels of hospitals showed that district hospitals had the highest rate of positive differences in revenue and medical centers had a tendency to increase the number of negative differences.This study was based on secondary data analysis.Recommendations for future research can use accurate data to calculate an individual hospital case mix index to refl ect disease risk and complexity, and to establish that the DRG case payment is reasonable.