| 摘要: | 目的：
本研究擬以腹腔鏡膽囊切除手術為例，探討實施TW-DRGs支付制度前後醫院住院醫療費用的影響比較及因應。
方法：
使用2009年及2010年全民健康保險研究資料庫之住院醫療費用清單明細檔及醫事機構基本資料檔案，以ACCESS資料庫軟體及EXCEL統計軟體，篩選出腹腔鏡膽囊切除手術個案費用資料，再以SPSS 21版統計軟體之T檢定、單因子變異數分析及薛費法檢定，對全國、特約別、分局別及權署別醫院的住院醫療費用進行差異性檢定分析。
結果：
TW-DRGs支付制度實施後全國醫院各項平均值為：住院日數減少0.06日，醫療費用減少347點、給付費用增加2,179點，給付獲得與成本支出的差異費用增加2,525點，報酬率達42.55%，報酬成長率增加6.08%。以T檢定分析在住院日數、診察費、病房費、檢查費、治療處置費、手術費、藥費、注射費、醫療費用、給付費用、差異費用、報酬率等項目，皆有顯著差異(P<0.05)，在管灌費、放射診療費、復健治療費、血液透析費、麻醉費、特材費、藥事服務費、精神治療費項目則無顯著差異。
結論:
以腹腔鏡膽囊切除手術個案分析，TW-DRGs支付制度實施後(1)全國醫院病人平均住院日及平均醫療費用較實施前減少，報酬率提升，住院日數長短與醫療費用具正相關性，顯示醫院的經營管理效益增加。(2)醫療費用成本管控，以醫學中心減少755點、東區分局醫院減少1,562點及軍方醫院(民眾診療)減少2,199點之降幅最多，優於其他同類別醫院。(3) 報酬率方面以區域級醫院的43.88%、北區分局醫院的45.19%及縣市立醫院的56.76%居同類別醫院之冠。(4) 報酬成長率部分以醫學中心的9.40%、東區分局醫院的9.85%及軍方醫院(民眾診療)的12.46%為同類別醫院成長最多者。
TW-DRGs支付制度的實施提升了醫院的經營效率及報酬率增加，但對醫療品質的提供是否不利，尚待進一步分析。
Objective:
The aim of this study is to compare reimbursement of inpatient care by national health insurance (NHI) before and after implementation of the Taiwan Diagnosis Related Groups (TW-DRGs) payment system, using laparoscopic cholecystectomy as an example.
Method:
The NHI reimbursement data of inpatient care for laparoscopic cholecystectomy during the period of 2009 to 2010 was collected. The inpatient medical expenditures data that we collected including: admissions (DD) and registry for contracted medical facilities (HOSB). The data were analyzed using SPSS software (SPSS V21). T-test, one-way ANOVA and Schefne’s method were performed to compare the differences between nationwide, contracted category and NHI regional division, as well as hospitals of different ownerships.
Results:
On average, after the implementation of TW-DGRs payment system there is a reduction of in-hospital stay by 0.06 day, a reduction of in-patient medical expenditure by 347 points, an increase of in-patient payment by 2,179 points. Meanwhile, there is a positive difference between revenue and expense by 2,525 points. after the implementation of TW-DGRs payment system , there is on average a 42.55 percent net revenue of inpatient reimbursement , with an increase by 6.08 percent for remuneration rate. The result of (T-test shows a p-value of less than 0.05) for the length of hospital stay, diagnostic fee, ward fee, laboratory examination fee , therapeutic treatment fee, operation fee, medication fee, injection fee, medical fee, reimbursement fee, fee differences and remuneration rate. There is no significant difference for tube feeding fee, radiology examination fee, rehabilitation fee, hemodialysis fee, anesthesia fee, special medical materials fee, medication service fee and psychiatric treatment fee.
Conclusion:
By analyzing these laparoscopic cholecystectomy cases, our study shows the implementation of TW-DRGs payment system has led to four effects. First, this is reduction of both the length of hospital stay and medical expenditure, and an incensement of remuneration. Such a positive correlation between the length of hospital stay and medical expenditure implies that there has been an increase in benefit for business management. Second, the reduction of medical expenditure is more significant in medical centers (with an average drop of 755 points), regional hospitals in East District (with an average drop of 1,562 points), and especially in military hospitals with the highest drop rate (drop rate of 2,199 points ).The results are better than similar type of hospitals. Third, the remuneration rate is relatively higher in regional hospitals, NHI regional division of northern district, municipal and province hospitals. Their remuneration rates were 43,88, 45.19, and 56.76 percent, respectively. Fourth, the remuneration growth rates were relatively higher in medical institution, NHI regional division of eastern district and military hospitals. Their remuneration growth rates were 9.40, 9.85, 12.46 percent, respectively. These are all the highest among their respective same type of hospitals.
Our study shows the implementation of TW-DRGs payment system increases both the efficiency of business operation and remuneration rate. However, it requires further study to clarify whether this system could also enhance the quality of medical care. |
