風險校正模式於健保論人計酬制度之應用：以高屏家醫群為例

The application of risk adjustment models to predict health expenditures under the capitation payment system in family medicine practice groups in the Kaoping Area

10.6288/TJPH201635105044

邱姵穎(Pei-Yin Chiu)；張清雲(Ching-Jun Chang)；蔡麗伶(Lih-Ling Tsai)；張玉蓉(Yu-Jung Chang)；謝慧敏(Hui-Min Hsieh)

論人計酬支付制度 ； 社區醫療群模式 ； 風險校正計價模式 ； 家庭醫師整合性照護計畫 ； capitation payment system ； community care medical group model ； risk-adjusted prediction model ； primary care physician integrated care plan

台灣公共衛生雜誌

35卷6期（2016 / 12 / 15）

595 - 608

繁體中文

目標：本研究結合現行的家庭醫師整合性照護計畫與論人計酬支付模式，分析高屏地區鄉村型與都市型家醫群診所就醫病患樣本，探討影響醫療費用之風險校正因子，並建構適合預測醫療費用模式。方法：本研究資料來源主要為2012-2013年全民健保申報資料，和高屏地區鄉村與都市二個區域有參加「家庭醫師整合性照護計畫」診所就診的病人資料。先隨機抽樣一個地區家醫群診所就醫病患病人作為訓練樣本，建立預測醫療費用的風險校正模型，並與其他兩組隨機抽樣家醫群診所樣本進行模型組內和組間的交叉驗證，以評估及確認風險調整模型之預測能力。結果：鄉村型與都會型家醫群驗證樣本人口學特性或醫療利用特質差異影響實際醫療資源利用。鄉村型病人六十歲以上比例和疾病嚴重度相對都會型家醫群樣本較高，反應在2013年實際醫療總費用分別為29,658點和25,087點。另外，風險校正費用預測模型隨著加入變項數而影響醫療費用的預測力，校正後預測力R^2從6.19%增加到40.20%。結論：當進行風險計價模型時，應考量適切的風險因子和合理的成長率，以增加風險計價的準確度和推估的敏感度，並且視地區費用成長特性和個別族群病人風險特質，適切地反應其醫療資源耗用狀況，以確保醫療照護就醫公平性及醫療資源有效分配與利用。

Objectives: The aims of this study were to investigate the risk factors associated with patients' health expenditures and to apply risk-adjusted medical expenditure prediction models using the primary care physician integrated care plan and the capitation payment model. Methods: Data were drawn from the 2012-2013 national health insurance (NHI) claims data and the primary care physician integrated care plan data for two primary care groups (one in a rural and the other in an urban area of the Kaoping area in southern Taiwan). We randomly selected one group of patients from one primary care group as a training set to conduct the risk-adjusted models, and compared two random samples from rural and urban primary care groups to assess the within and between group validity of the prediction models. Results: This study supported an association between patients' demographic or comorbid characteristics and health expenditures in the rural and urban primary care patient groups. Patients in the rural area were age sixty or older and their health expenditures in 2013 were greater than those in the urban group (NTD 29,658 vs. 25,087). In addition, the model's goodness-of-fit measured as adjusted R^2 increased from 6.19% to 40.20% when more risk factors were added to the risk-adjusted health expenditure models. Conclusions: When risk-adjusted models to predict medical costs are used, appropriate risk factors and reasonable growth rates need to be considered in order to increase the accuracy and sensitivity of the prediction of medical costs. Moreover, geographic variability also needs to be considered in order to reflect the consumption of medical resources in different areas and to ensure the horizontal equity and efficient allocation of medical resources across rural and urban areas.

1. 朱育增、吳肖琪、李玉春、賴美淑、譚醒朝(2010)。探討共病測量方法於健保次級資料之應用。台灣衛誌，29，191-200。
   連結：
2. 張睿詒、賴秋伶(2004)。論人計酬醫療費用預測之基礎。台灣衛誌，23，91-9。
   連結：
3. 謝孟甫、張睿詒(2006)。處方資訊用於台灣風險校正模型之初探。台灣衛誌，25，189-200。
   連結：
4. 羅紀琼(2015)。台灣地區論人計酬試辦計畫之評估―以醫院忠誠病人模式為例。台灣衛誌，34，463-75。
   連結：
5. 衛生福利部中央健保署：全民健康保險論人計酬試辦計畫。http://www.nhi.gov.tw/Resource/bulletin/4518_1020022401%E5%85%AC%E5%91%8A%E9%99%84%E4%BB%B6.pdf。引用2016/03/09。National Health Insurance Administration, Ministry of Health and Welfare, R.O.C. (Taiwan). Capitation payment system of National Healthcare Insurance. Available at: http://www.nhi.gov.tw/Resource/bulletin/4518_1020022401%E5%85%AC%E5%91%8A%E9%99%84%E4%BB%B6.pdf. Accessed March 9, 2016. [In Chinese]
6. 衛生福利部中央健保署：全民健康保險家庭醫師整合性照護計畫。http://wwwnhigovtw/Resource/we b d a t a/25686_2_1020004147-1.pdf。引用2016/03/09。National Health Insurance Administration, Ministry of Health and Welfare, R.O.C. (Taiwan). Primary care physician integrated care plan of National Health Insurance. Available at: http://www.nhi.gov.tw/Resource/webdata/25686_2_1020004147-1.pdf. Accessed March 9, 2016. [In Chinese]
7. Anderson, GF,Steinberg, EP,Holloway, J,Cantor, JC.(1986).Paying for HMO care: issues and options in setting capitation rates.Milbank Q,64,548-65.
8. Bambra, CL,Copeland, A.(2013).Deprived areas will lose out with proposed new capitation formula.BMJ,347,f6146.
9. Bang, JH,Hwang, SH,Lee, EJ,Kim, Y.(2013).The predictability of claim-data-based comorbidityadjusted models could be improved by using medication data.BMC Med Inform Decis Mak,13,128.
10. Barnes, AJ,Unruh, L,Chukmaitov, A,van Ginneken, E.(2014).Accountable care organizations in the USA: types, developments and challenges.Health Policy,118,1-7.
11. Barr, B,Bambra, C,Whitehead, M.(2014).The impact of NHS resource allocation policy on health inequalities in England 2001-11: longitudinal ecological study.BMJ,348,g3231.
12. Chang, HY,Lee, WC,Weiner, JP.(2010).Comparison of alternative risk adjustment measures for predictive modeling: high risk patient case finding using Taiwan's National Health Insurance claims.BMC Health Serv Res,10,343.
13. Chang, RE,Lai, CL.(2005).Use of diagnosis-based risk adjustment models to predict individual health care expenditure under the National Health Insurance system in Taiwan.J Formos Med Assoc,104,883-90.
14. Chukmaitov, A,Harless, DW,Bazzoli, GJ,Carretta, HJ,Siangphoe, U.(2015).Delivery system characteristics and their association with quality and costs of care: implications for accountable care organizations.Health Care Manage Rev,40,92-103.
15. Cowen, ME,Dusseau, DJ,Toth, BG,Guisinger, C,Zodet, MW,Shyr, Y.(1998).Casemix adjustment of managed care claims data using the clinical classifications for health policy research method.Med Care,36,1108-13.
16. Cucciare, MA,O'Donohue, W.(2006).Predicting future healthcare costs: how well does risk-adjustment work?.J Health Organ Manag,20,150-62.
17. Culyer, AJ(ed.),Newhouse, JP(ed.)(2000).Handbook of Health Economics.Amsterdam, Netherlands:Elsevier.
18. Elixhauser, A,Steiner, C,Harris, DR,Coffey, RM.(1998).Comorbidity measures for use with administrative data.Med Care,36,8-27.
19. Goroll, AH,Schoenbaum, SC.(2012).Payment reform for primary care within the accountable care organization: a critical issue for health system reform.JAMA,308,577-8.
20. Hauck, K,Shaw, R,Smith, PC.(2002).Reducing avoidable inequalities in health: a new criterion for setting health care capitation payments.Health Econ,11,667-77.
21. Kuo, RN,Lai, MS.(2010).Comparison of Rx-defined morbidity groups and diagnosis- based risk adjusters for predicting healthcare costs in Taiwan.BMC Health Serv Res,10,126.
22. Levine, R.(2001).Capitation: a strategy that could have a future.Healthc Financ Manage,55,41-3.
23. McWilliams, JM,Song, Z.(2012).Implications for ACOs of variations in spending growth.N Engl J Med,366,e29.
24. Newhouse, JP.(1998).Risk adjustment: where are we now?.Inquiry,35,122-31.
25. Newhouse, JP,Buntin, MB,Chapman, JD.(1997).Risk adjustment and Medicare: taking a closer look.Health Aff,16,26-43.
26. Newhouse, JP,Sloss, EM,Manning, WG, Jr,Keeler, EB.(1993).Risk adjustment for a children's capitation rate.Health Care Financ Rev,15,39-54.
27. Ortiz, J,Tang, CY,Lin, YL,Masri, MD.(2015).Primary care clinics and accountable care organizations.Health Serv Res Manag Epidemiol,2,pii:2333392815613056.
28. Paul, DP, 3rd,Graves, H,Arroyo, D,Neal, K,Daniel, B,Coustasse, A.(2014).Managed care and accountable care organizations.Proceedings of Northeast Business & Economics Association 2014 Forty-First Annual Meeting,West Long Branch, NJ:
29. Pope, GC,Adamache, KW,Walsh, EG,Khandker, RK.(1998).Evaluating alternative risk adjusters for Medicare.Health Care Financ Rev,20,109-29.
30. Rice, N,Smith, PC.(2001).Capitation and risk adjustment in health care financing: an international progress report.Milbank Q,79,81-113.
31. Rice, N,Smith, PC.(2001).Ethics and geographical equity in health care.J Med Ethics,27,256-61.
32. Rittenhouse, DR,Shortell, SM,Fisher, ES.(2009).Primary care and accountable care-two essential elements of delivery-system reform.N Engl J Med,361,2301-3.
33. van Vliet, RCJA.(1992).Predictability of individual health care expenditures.J Risk Insur,59,443-61.
34. 張世芳(2002)。高雄=Kaohsiung，國立高雄第一科技大學風險管理與保險系=Department of Risk Management and Insurance, National Kaohsiung First University of Science and Technology。
35. 張舒婷(2005)。台北=Taipei，國立台灣大學醫療機構管理研究所=Graduate Institute of Health Care Organization Administration, National Taiwan University。
36. 蔡美卿、楊美雪、吳聰慧、余欣蓉、曾若嫻(2012)。不同合併症指標於成人氣喘住院費用之預測表現。若瑟醫護雜誌 ，6，6-19。