調高健保給付對醫療品質之影響：以2005年自然產給付調高為例

The Impact of a Raise in Reimbursement: A Payment Increase for Vaginal Delivery in 2005 as an Example

10.6277/TER.201912_47(4).0004

連賢明(Hsien-Ming Lien)；韓幸紋(Hsing-Wen Han)

剖腹產 ； 誘發性需求 ； 醫療品質 ； cesarean section ； induced demand ； healthcare quality

經濟論文叢刊

47卷4期（2019 / 12 / 01）

621 - 664

繁體中文

2005年5月健保局將自然產給付加倍，調整至與剖腹產給付一致，期望透過自然產給付增加，來降低剖腹產率並改善醫療品質。這自然產給付增加提供了一個檢視給付提高對醫療品質改善機會。本文使用2004與2006年生產案件，以健保給付當作醫師所得的替代變數，醫療品質則以剖腹產率、住院天數、再住院率進行觀察，分析醫師所得增加和醫療品質間因果關係。爲控制醫療時無法觀察因子，估計時選用初產產婦，並採用「一階差分」方式來排除內生性偏誤。結果顯示給付增加對剖腹產率沒有顯著關係，但原先自然產比例較高醫師剖腹產率卻有降低；另外，自然產再住院率也顯著下降。我們進一步針對幾個解釋剖腹產偏低效果進行檢驗，發現產婦個人偏好剖腹產是一個可能原因。最後，我們發現這給付調整效果並未外溢到同醫院的婦科、兒科治療。

In May 2005, Bureau of National Health Insurance doubled the reimbursement for vaginal delivery to the same rate as paid for cesarean section (c-section) in order to reduce the c-section rate and improve the quality of care. This reimbursement adjustment provides an excellent opportunity to examine whether such a payment increase can improve healthcare quality. Using obstetric cases of firstborns in 2004 and 2006 from National Health Insurance Data, this study examines if there was a negative relation between quality indicators (e.g. c-section, re-admission, and length of stay) and doctor's income, measured in terms of payments paid by NHI for baby delivery. To control for the endogenous bias, the study employs ＂first-difference＂ methods to attenuate the bias arising from unobserved factors, and restricts the sample to firstborn babies. Our results indicate that the doctor's income and c-section rate is statistically uncorrelated on the whole, but negatively related for doctors who previously had a lower percentage of c-sections. Additionally, we found the payment reduces both the 14 and 30 days re-admission after vaginal delivery. Furthermore, the analysis indicates that one explanation- a c-section is preferred by women for the sake of personal reasons- is largely consistent with our empirical findings. Finally, we found the effect of the payment increase did not spill over to gynecology or pediatric services in the same hospital.

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