健保論病例計酬對不同層級醫療機構之公平性之探討──以不同生產模式為例

Investigating the Fairness of the Health Insurance Case Payment System in Medical Institutions of Different Levels-Using Different Delivery Models as Examples

目的：臺灣全民健康保險將生產給付採論病例計酬並推動同病同酬，縮小不同層級健保給付的差距，本研究就不同層級醫療機構於生產服務之資源耗用、費用申報及其獲利比較其差異與影響因素。方法研究採回溯性世代追蹤研究法，運用國家衛生研究院提供2010年版全民健保資料庫之百萬抽樣歸人檔進行分析，研究擷取分析2009年間有生產記錄之產婦共7,845人，追蹤其生產前280天之所有產檢與醫療利用記錄，以ANOVA及回歸分析等統計方法：，分析不同層級醫療機構其生產的醫療資源耗用、差額與影響因素。結果：研究對象生產方式以自然生產者佔63.17％較高，剖腹產者為36.52％；比較不同層級醫療機構生產之平均資源耗用點數分別為27,939.99、25,642.28、23,992.85、21,863.79達統計顯著差異；但申報給付金額減去資源耗用之差額點數分別為8,657.07、8,608.30、8,635.72、7,225.06，基層院所則低於其他層級醫療機構並達統計顯著差異。影響產婦生產醫療資源耗用成正相關因素有住院天數、多胞胎、生產方式、醫院權屬別、健保申報案件類型。結論：不同醫療層級醫療機構產婦醫療資源耗用與申報費用確實有差異，但由於醫學中心等層級較高之醫療機構在每一生產之健保給付額仍高於其他層級，因此即使考量同病同酬前提下，層級不同之醫療機構仍須存在風險調整之費用。

Purposes: The Taiwan National Health Insurance System initiated a case payment scheme for reimbursement of child delivery, promoting “same disease, same reimbursement” to reduce the difference in payments among different levels of health insurance. This study compares the differences and influ-encing factors of resource consumption, expense declaration, and profits from obstetric services in medical institutions of different levels. Methods: This study is a retrospective cohort study. The analysis uses one million pregnant women sample cases from the 2010 National Health Insurance Database provided by the National Health Research Institutes. This study captures and analyzes 7,845 pregnant women with delivery records in 2009 and traces all prenatal and medical utilization records 280 days before delivery. ANOVA, re-gression analysis, and other statistical methods were used to analyze healthcare resource consump-tion, differences, and factors influencing deliveries in medical institutions of different levels. Results: The majority of study subjects had natural deliveries (63.17%), while 36.52% had Caesarean sections. The average resource consumption points of deliveries among medical institutions of medical centers was 27,939.99, district hospitals was 25,642.28, regional hospitals 23,992.85 and physician clinics 21,863.79,which had statistical significance. However, the differences in declared reimbursement and resource consumption points were 8,657.07, 8,608.30, 8,635.72, and 7,225.06, respectively, with the difference in physician clinics lower than medical institutions of other levels, which had statistical significance. Factors that are positively or negatively correlated with medical resource consumption in deliveries of pregnant women include number of days of hospitalization, multiple births, delivery methods, hospital ownership, and healthcare insurance case declaration type. Conclusions: The results show differences in medical resource consumption and reimbursement declaration for pregnant women in medical institutions of different levels. However, as medical centers and other higher level medical institutions have higher healthcare insurance payments for every delivery compared to lower level medical institutions, even considering the concept of “same disease, same reimbursement,” risk adjustment fees still exist in medical institutions of different levels.