美國老人醫療保險急性後期照護的發展

The Development of Medicare post-acute Care in USA

10.6288/TJPH2006-25-05-01

戴桂英(Guey-Ing Day)；吳淑瓊(Shwu-Chong Wu)；江東亮(Tung-Liang Chiang)

美國老人醫療保險 ； 急性後期照護 ； 前瞻式支付制度 ； Medicare ； post-acute care PAC ； prospective payment system PPS

台灣公共衛生雜誌

25卷5期（2006 / 10 / 01）

323 - 329

繁體中文

美國實施急性醫院前瞻式支付制度後，急性後期照護蓬勃發展。台灣自1995年實施全民健保，為控制醫療利用也提出醫院前瞻式論病例支付之擬議。本研究目的在探討美國Medicare的急性後期照護供給成長趨勢、利用狀況、影響急性後期照護消長的政策，以及提出對台灣的啟示。我們發現美國Medicare急性後期照護(1) 1997年起受預算中平法案影響供給成長趨緩；(2) Medicare約有12%的花費用於居家健康照護、技術性護理機構、復健醫院和長期照護醫院；(3)機構式服務要自負額、每日定額等部分負擔；(4)以四種前瞻式支付制度擬限制其過度成長。我們建議台灣於推動醫院前瞻式論病例支付制度時，宜(1)同時研議急性後期照護的範圍、支付方式和部分負擔設計，且避免費用過度轉成民眾自付；以及(2)思考如何將急性醫療與急性後期照護配套，以求服務連續完整，並設計客觀的成果評估方式。

Following the implementation of Medicare's acute care hospital prospective payment system in the USA in 1984, Medicare spending for post-acute care (PAC) began to grow rapidly. Taiwan's National Health Insurance (NHI), which was implemented in 1995, is planning a hospital case payment system to avoid such unnecessary utilization. The purpose of the current study was to review the trend of post-acute care providers and spending for Medicare from the early 1990s to 2004, prospective payments for post-acute care providers in the USA, and the impact of the changes in Medicare payment policies. The main findings of the study are as follows: (1) the number of PAC providers increased rapidly across all settings after implementation of DRGs payment, but increased slowly, or decreased in facilities such as home health agencies, after implementation of PPS for PAC providers, following mandates in the Balanced Budget Act of 1997, (2) PAC made up about 12% of Medicare's total spending, (3) beneficiaries should pay deductible or co-payments while using institutional PAC, and (4) in order to control spending, Medicare's system of PAC payments should be converted to prospective payments. When the prospective case payment system is implemented in Taiwan, we: (1) recommend that the coverage, the payment system, and the co-payments of post-acute care should be redesigned at the same time and (2) suggest that the hospital case payment system should be planned carefully to make post-acute care integrated with acute care.

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