甲狀腺切除論病例計酬之甲狀腺癌與良性甲狀腺疾患醫療資源耗用分析

The Analysis of He Resource Utilization for Patients With Thyroid Cancer and Benign Thyroid Diseases With Thyroidectomy Case Payment

10.6288/TJPH2002-21-06-01

吳仁佑(Jen-You Wu)；葉玲玲(Ling-Ling Yeh)；閻愷正(K. Lawrence Yen)；黃達夫(Andrew T. Huang)

診斷關聯群 ； 甲狀腺癌 ； 論病例計酬 ； 甲狀腺切除術 ； 良性甲狀腺疾患 ； DRGs ； Thyroid Cancer ； Case Payment ； Thyroidectomy ； Benign Thyroid Diseases.

台灣公共衛生雜誌

21卷6期（2002 / 12 / 01）

387 - 396

繁體中文

目標：本研究以HCFA DRGs為架構，分析同屬DRG290之甲狀腺疾患兩類病人實施甲狀腺切除術住院人次醫療費用與住院天數，並探討不同支付方式與不同醫院層級之甲狀腺癌與良性甲狀腺疾患醫療資源耗用的差異性，作為日後全面實施DRGs的參考。方法：本研究資料來源為1999年3月至12月全民健保住院申報資料。研究對象為符合HCFA DRG 290定義ICD-9主手術碼之所有實施甲狀腺切除術住院人次，分析不同支付方式與不同醫院層級論病曆與非論病例計酬甲狀腺癌與良性甲狀腺疾患病人之醫療費用、住院日數等醫療資源耗用，以及不同醫院實施甲狀腺切除術病人中甲狀腺病人所佔比率之分布情形。結果：整體而言，實施甲狀腺切除術之甲狀腺癌病人平均住院醫療費用及住院天數均高於良性甲狀腺疾患，而且國內實施甲狀腺切除術的病人92%不是甲狀腺癌病人。無論是論病例計酬個案或非論病例計酬個案，甲狀腺癌病人平均費用與住院天數均高於良性甲狀腺疾患。核實申報個案除醫學中心外，區域醫院及地區醫院甲狀腺癌病人平均費用均高於良性甲狀腺疾患。而定額申報個案不同醫院層級之甲狀腺癌病人平均費用也均高於良性甲狀腺疾患。非論病例計酬個案之甲狀腺癌病人平均費用也均遠高於良性甲狀腺病患，其中以醫學中心差異最大，達28,998元。結論：健保局未來將以HCFA DRGs為主要架構全面實施DRGs。HCFA DRG 290範圍包括本研究論病例計酬與非論並病例計酬甲狀腺切除術病人，亦即同時包含甲狀腺癌與良性甲狀腺疾患病人。根據本研究分析結果，甲狀腺癌病人醫療資源耗用明顯高於良性甲狀腺疾患，而且在臨床上亦屬兩種不同的治療方式，因此未來如果將甲狀腺切除術之甲狀腺癌與良性甲狀腺疾患歸為同一組DRG，將對更需手術前謹慎評估且處置困難度高的甲狀腺癌疾患產生給付過低的現象。國內實施甲狀腺切除術之良性甲狀腺病患病人比例過度頻繁，恐有濫用醫療資源與不當醫療之虞。DRGs如果以全國甲狀腺切除病例之平均醫療費用為定價基準，則將過度鼓勵醫院進行不必要之手術，亦間接懲罰嚴格遵循各類甲狀腺手術治療準則之醫療機構。上述皆值得全民健保局重視並加以改進。

Objective: Based on the framework of HCFA DRGs, we conducted an analysis of the relationship between medical expenditures and the number of hospital days in patients who undergo thyroid surgery in. Taiwan. It compares the differences in surgery for thyroid cancer and benign thyroid diseases, in relation to the two types of payment system and three levels of hospitals, in which these operations were performed. It is our hope that these findings will contribute to the design of the DRGs payment system in the immediate future. Method: Our data set utilizes claims data recorded by the Bureau of National Health Insurance (BNHI) for in-patients from March to December 1999. Subjects of interest were those who were admitted for thyroid surgery and were identified using the HCFA DRG 290 ICD-9 thyroid gland surgical codes. These subjects were then categorized into case payment and non-case payment groups, and further classified into cancer and non-cancer groups. Total health expenditures paid by the BNHI and the hospital days for each subgroup were evaluated. The differences were then determined according to the three levels of hospitals in which the procedure was performed. Results: A general trend prevailed in that thyroid cancer patients incurred greater hospital costs as well as longer days of hospitalization than benign diseases patients, whether the payment system was case payment or not. For the non-case payment subjects, the discrepancy in cost was evident in all hospitals, with the largest variation seen in the medical centers, reaching an average of NT$28,998. The predominant form (92%) of thyroid surgery performed in this country IS for benign thyroid diseases. Conclusion: Based on our analysis, the consequence of HCFA DRGs design encourages biased patient selection by hospitals to operate on benign diseases, which leads to unnecessary surgery by promising better financial returns. The risk is thus shifted to hospitals which follow a more stringent surgical indication and treats a greater proportion of cancer patients. Such a payment system runs counter to promoting good surgical practice.

1. (1997)。全民健康保險實施二年評估報告。臺北:行政院衛生署。
2. (1999)。中華民國全民健康保險統計。臺北市:中央健康保險局。
3. American Association of Clinical Endocrinologists, American College of Endocrinology(1995).AACE Clinical Practice Guidelines for The Evaluation and Treatment of Hyperthyroidism and Hypothyroidism.Endocrine Practice,1
4. American Association of Clinical Endocrinologists, American College of Endocrinology(1996).AACE Clinical Practice Guidelines for The Diagnosis and Management of Thyroid Nodules.Endocrine Practice,2
5. Iezzoni, L. I., Henderson, M. G., Bergman, A., Drews, R. E.(1991).Purpose of Admission and Resources Use During Cancer Hospitalization.Health Care Financing Review,13(2)
6. Jackson, T., Street, A..Casemix Differences Within Cancer Diagnosis Related Groups.National Health and Medical Research Council.
7. Linn, B. S., Robinson, D. S.(1988).The possible impact of DRGs on nutritional status of patients having surgery for cancer of the head and neck.Journal of the American Medical Association,260
8. Lion, J., Henderson, M., Malbon, A., Bergman, A., Come, S.(1987).Case Mix and Charges for Inpatient and Outpatient Chemotherapy.Health Care Financing Review,8(4)
9. Maxwell, J. G., Scallion, R. R., White, W. C.(1996).Fine-Needle Aspiration Cytology and Thyroid Surgery in the Community Hospital.American Journal of Surgery,172
10. Munoz, E., Chalfin, D., Rosner, F., Cohen, J. R., Mulloy, K., Wise, L.(1988).Hospital Cost, Cancer Patient and Medical Diagnosis-Related Groups.Oncology,45
11. Munoz, E., Seltzer, V., Sterman, H., Cohen, J. R., Goldstein, J., Wise, L.(1989).Hospital Cost, Cancer Patient, and Gynecology Diagnostic Related Groups.Gynecologic Oncology,33(2)
12. Scheffler, R. M., Phillips, K. A.(1989).Cancer Care and Cost DRGs and Beyond.Ann Arbor, MI.:Health Administration Press.
13. 莊逸洲 Chuang, Yi-Chou、 陳怡如 Chen, Yi-Ru、 史麗珠 See, Lai-Chu、 陳理 Chen, Lee(1999)。全民健保實施陰道分娩論病例計酬制對醫療資源使用方式的影響－以某財團法人醫學中心為例 The Impact of Case Payment System on the Utilization of Vaginal Ddlivery Under National Health Insurance in Taiwan-unsin Data in a Non-for-profit Medical Center。中華公共衛生雜誌 Chinese Journal of Public Health，18(3)
14. 錢慶文 Chien, Richard Ching-Wen、 黃三桂 Huang, San-Quei(2000)。論病例計酬制度對住院日數及醫療費用之影響︰以痔瘡切除手術為例 The Impact of Case Payment System on the Length of Stay and Medical Expenditure of Inpatient Services: A Study of Hemorrhoidectomy。公共衛生 Public Health Quarterly，26(4)

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