醫療補貼政策對醫療利用之影響－以臺北市兒童醫療補助計畫為例

Effect of a Subsidy Program on Medical Care Utilization-Results from the Medical Subsidy Program for Children in Taipei City

10.6200/TCMJ.2006.3.3.09

許君強(Chun-Chyang Hsu)；林澤余(Tze-Yu Lin)；沈希哲(Shi-Che Shen)；張嘉莉(Chia-Li Chang)；湯澡薰(Chao-Hsiun Tang)

兒童醫療補助計畫 ； 醫療利用 ； 替代效果 ； children's medical care subsidy program ； medical care utilization ； substitution effect

北市醫學雜誌

3卷3期（2006 / 03 / 01）

268 - 287

繁體中文

目的：臺北市政府衛生局於民國84年12月25日初次提出「臺北市兒童醫療補助計畫」，期望能減少兒童就醫之經濟障礙。臺北市政府實施兒童醫療補助計畫期間政策內容的改變，可能造成兒童醫療利用行為的改變，恰好提供一個自然實驗的機會供研究者進行探討。本研究目的為探討臺北市0至6歲兒童於民國90年2月1日門診醫療補助改變前後一年期間，其門診、急診與住院利用情形之變化，以研究因醫療補助政策的調整使得門診、急診補貼條件不同，其所引發的門急診醫療相對價格變動，是否會造成門、急診間的替代效果。兒童父母是否選擇以自付價格較低之急診取代自付價格較高之門診，進而影響兒童之住院醫療利用等議題。方法：本研究之研究對象設定為於民國90年2月1日滿1-6歲以及於民國91年2月1日滿1-6歲之兒童。資料蒐集方式係以民國89年戶籍檔合乎條件之兒童身份證字號，用其擷取中央健保局民國89年至91年之所有相關醫療利用資料，並以兒童身份證字號串連內政部出生檔中之兒童出生資料以及兒童父母之年齡及教育程度資料。本研究係以民國89年戶籍檔中設籍臺北市之兒童作為實驗組，以臺北市外之其他縣市兒童為控制組進行研究分析。經資料檢誤後，本研究利用套裝統計軟體SAS 8.0進行統計分析，所使用的統計方法包括樣本基本資料之描述性分析、實驗組與控制組基本資料之卡方檢定、各控制變項對依變項之相關分析、是否就醫之羅吉斯迴歸分析、以及醫療補助政策改變對於兒童醫療利用次數之負二項迴歸分析。結果：研究結果顯示，相較於全國除臺北市以外之其他縣市的兒童而言，臺北市0-6歲兒童於民國90年2月1日至91年1月31日一年期間較民國89年2月1日至90年1月31日一年期間之門診利用次數顯著減少，檢傷分類一、二級急診利用次數無顯著的差異，檢傷分類三、四級急診利用次數有顯著的增加，而住院利用次數及住院人日數則無顯著的差異。結論：研究結果證實了此醫療補助政策內容的改變會誘導父母以急診替代門診，造成急診檢傷分類中較不緊急的三、四級案件的使用頻率增加，不但浪費緊急醫療的資源，辜負了衛生局濟貧濟急的美意，也可能分散與排擠了急重症患者的照護，間接影響了整體急診醫療的照護品質。在以後續住院利用來檢視增加的急診利用對於兒童健康結果之影響方面，研究結果顯示並沒有因為提供候診時間較短且價格較低的及時性急診醫療照護，而使得兒童病情在急診時受到適當控制，而降低後續住院之使用。因此，本研究建議衛生主管機關能重新研議補助內容，以提供更適切之補助。

Background and Purpose: The purpose of this study was to examine the changes various services for children residing in Taipei City before and after February 1st, 2001 when the subsidy of outpatient care services has been dissolved. Specifically, this study sought to provide answers to the following two questions: First, Was there a substitution effect resulting from changes in relative price of outpatient services and emergency services? Second, Were children’s inpatient services been affected by the changes in policy? Methods: This study examined the use of outpatient services, emergency services and inpatient services covered by the National Health Insurance in 2000 and 2001 for children residing in Taipei City (the study group). The study group was compared with the control group, which included all the other children residing in cities and counties other than Taipei City. Results: Results from this study indicated that, comparing to children in other counties and cities in Taiwan, children aged 1-6 in Taipei City had lower frequency of outpatient care utilization in the post-policy-change period, comparing to the pre-policy-change period. At the same time, they also consumed more of the third and fourth level of emergency care. This result suggested that parents might substitute emergency care for outpatient services due to the changes in relative price. Finally, there was no significant difference in utilization of inpatient care. Conclusion: The findings from this study suggested that parents were sensitive to the decrease in relative price of emergency care due to the policy change and substituted away from outpatient care toward emergency care. This might not only present a waste of the emergency medical resources, but also has adverse effects on the quality of emergency care. Moreover, there were no significant reduction of hospitalization; there is, no actual benefit of children's health outcome being observed. Results from this study suggest that a further evaluation of government subsidy program is needed in order to facilitate more efficient use of medical care resources.