健保實施DRGs對醫學中心之影響：CTT與IRT之比較

Influence and Impact on Medical Centers under DRGs: CTT vs IRT

10.6595/BDCM.2007.2(2).5

錢才瑋(Tsair-Wei Chien)；王文中(Wen-Chung Wang)

診斷關係群 ； Rasch分析 ； 古典測驗理論 ； 試題反應理論 ； Winsteps ； DRGs ； Rasch analysis ； CCT ； IRT ； Winsteps

致遠管理學院學報

2_2期（2007 / 09 / 01）

89 - 106

繁體中文

This study examined the impact of medical centers in Taiwan under DRGs. The aims were set at (1) knowing the influence in the first and following 4 years, (2) exploring the statistically significant different starting time under DRGs, (3) evaluating the revenue declining and rebounding cut-off point in the period of DRGs implementation time. The DRGs costs of all the 17 medical centers were calculated for the year 2004 on 185 DRGs resulting from those 6 major diagnostic categories of No. 3, 9, 11, 13, 23 and 24. Rasch analysis　with Winstpes software was used examining a total of 94,536 discharges of DRGs to compare the revenue changes through those two ways of classic test theory and item response theory. The results shows that government-run hospitals will be influenced much more than the private ones. Only non-profit run hospitals were shown no statistically significant difference in revenue decline across future 4 year under DRGs. Southern and Central medical centers in Taiwan were said to be improved in revenue at the fourth upcoming year. There are a few differences resulting from the methods of IRT and CTT, which might be attributed to the unfitted April data removed from this study through Rasch analysis of IRT.

This study examined the impact of medical centers in Taiwan under DRGs. The aims were set at (1) knowing the influence in the first and following 4 years, (2) exploring the statistically significant different starting time under DRGs, (3) evaluating the revenue declining and rebounding cut-off point in the period of DRGs implementation time. The DRGs costs of all the 17 medical centers were calculated for the year 2004 on 185 DRGs resulting from those 6 major diagnostic categories of No. 3, 9, 11, 13, 23 and 24. Rasch analysis　with Winstpes software was used examining a total of 94,536 discharges of DRGs to compare the revenue changes through those two ways of classic test theory and item response theory. The results shows that government-run hospitals will be influenced much more than the private ones. Only non-profit run hospitals were shown no statistically significant difference in revenue decline across future 4 year under DRGs. Southern and Central medical centers in Taiwan were said to be improved in revenue at the fourth upcoming year. There are a few differences resulting from the methods of IRT and CTT, which might be attributed to the unfitted April data removed from this study through Rasch analysis of IRT.

1. 陳婉茗、吳肖琪(2005)。模擬DRGs實施對我國醫院的財務衝擊。台灣公共衛生雜誌，24(4)，306-314。
   連結：
2. 陳琇玲、楊銘欽、薛亞聖、楊捷如(2005)。健保局DRGs對台灣病例變異解釋力之初探。台灣公共衛生雜誌，24(6)，548-560。
   連結：
3. Andrich, D.(1978).A rating scale formulation for ordered response categories.Psychometrika,43,561-573.
4. Blais, M.(2003).Have you heard we're having a revolution? The coming of modern test theory.Journal of Personality Assessment,80(2),208-210.
5. Bond, T. G.,Fox, C. M.(2001).Applying the Rasch model: fundamental measurement in the human sciences.Lawrence Erlbaum Associates.
6. Brogden, H. E.(1977).The Rasch model, the law of comparative judgement and additive conjoint measurement.Psychometrika,42,631-634.
7. Coulam, R. F.,Gaumer, G. L.(1994).Medicare's prospective payment system: a critical appraisal.Health Care Finamc Rev.
8. Cronbach, L. J.(1951).Coefficient alpha and the internal structure of tests.Psychometrika,16,297-334.
9. Embretson, S. E.(1996).The new rules of measurement.Psychological As-sessment,8,341-349.
10. Embretson, S. E.,Reise, S. P.(2000).Item Response Theory for Psychologists. Mahwah.New Jersey:Lawrence Erlbaum.
11. Feinglass, J.,Holloway, J. J.(1991).The initial impact of the medicare propective payment system on U.S.health care: a review of the literature.Med Care Rev,48,91-115.
12. Fetter, B. B.(1984).Diagnosis related groups: the product of the hospital.Clin Res,42,336-340.
13. Fetter, B. B.,Shin, Y.,Freeman, J. I.,Thompson, K. D.(1980).Case mix difinition by diagnosis-related groups.Med Care,18,1-53.
14. Fox, C. M.,Jones, J. A.(1998).Uses of Rasch modeling in counseling psychology research.J Couns Psychol,45,30-45.
15. Guterman, S.,Dobsin, A.(1986).Impact of the Medicare prospective paryment system for hospital.Health Care Financ Rev,7,97-114.
16. Guterman, S.,Eggers, P. W.,Riley, G.,Greene, T. F.,Terrell, S. A.(1988).The first 3 years of Medicare prospective payment: an overview.Health Care Finac Rev,9,67-77.
17. Hambleton, R. K.,Swaminathan, H.(1985).Item response theory: Principles and applications.Boston, MA:Kluwer-Nijhoff.
18. Han, J.,Kamber, M.(2006).Data Mining: Concepts and Techniques.Morgan Kaufmann.
19. Likert, R.(1932).A technique for the measurement of attitudes.Archives of Psychology,140,32-66.
20. WINSTEPS [computer program]
21. Nunnally, J. C.,Bernstein, I. H.(1994).Psychometric Theory.N.Y.:McGraww-Hill.
22. Pirson M,Martins D,Jackson T,Dramaix M,Leclercq P.(2005).Prospective casemix-based funding, analysis and financial impact of cost outliers in all-patient refined diagnosis related groups in three Belgian general hospitals.Eur J Health Econ,7(1),55-65.
23. Prieto, L.,Lamarca, R.,Santed, R.,McFarlane, D.,Sanzo, J. M.,Alonso, J.(1997).Reducing the items of the Nottingham Health Profile.Qual Life Res,6,703.
24. Rasch, G.(1960).Probabilistic models for some Intelligence and attainment tests.Chicago:University of Chicago Press.
25. Sheu, C. F.,Chen, C. T.,Su, Y. H.,Wang, W. C.(2005).Using SAS PROC NLMIXED to fit item response theory models.Behav Res Methods,37,202-218.
26. Stevens, S. S.(1946).On the theory of scales of measurement.Science,103,677-680.
27. Thissen, D.,Billeaud, K.,McLeod, L.,Nelson, L.(1997).A brief introduction to item response theory for items scored in more than two categories.Paper presented at the National Assessment Governing Board Achievement Levels Workshop, Boulder.
28. Wright, B. D.,Masters, G. N.(1982).Rating Scale Analysis.Chicago, Ill:MESA Press.
29. Wright, B. D.,Mok, M.(2000).Rasch models overview.Journal of applied measurement,1,83-106.
30. 王文中(1997)。測驗的建構：因素分析還是Rasch分析？。調查研究，3，129-166。
31. 王文中(2004)。Rasch測量理論與其在教育和心理之應用。教育與心理研究，27，637-694。
32. 王文中(2006)。模基方法學的發展與應用：從IRT的發展講起。「模基統計方法學：機會、挑戰、威脅」第三屆測量統計方法學學術研討會，嘉義:
33. 王文中、呂金變、吳毓瑩、張郁雯、張淑慧(1999)。教育測驗與評量－教室學習觀點。台北:五南。
34. 全民健康保險住院診斷關聯群：Tw-DRGs支付原則
35. 健保局(2004)。全民健康保險住院診斷關聯群支付規劃報告。
36. 錢才瑋、王文中、梁安億(2007)。健保DRGs費用上下限臨界點設定之研究。福爾摩莎期刊，3(1)，55-66。
37. 錢才瑋、王文中、陳年興、林宏榮(2007)。建置資訊模組篩選費用異常以因應健保DRGs之實施。醫療資訊雜誌，16(1)，15-26。
38. 錢才瑋、王文中、陳年興、蘇世斌(2007)。資訊模組提供健檢訊息之應用研究。醫療資訊雜誌，16(2)，13-28。
39. 錢才瑋、王文中、陳承德(2006)。Rasch分析在醫療界應用。台南:聞道出版社。
40. 錢才瑋、王文中、楊美雪、梁安億(2007)。健保Tw-DRGs費率調整對醫院營收影響之評估研究。醫院