勞保門診醫療費用支付制度對醫療供給者診療行為之影響

The Effect of Changes of Opd Payment System of Labor Insurance on the Providers Medical Care Behavior

10.6288/CJPH1994-13-04-04

郭信智(Hsin-Chih Kuo)；楊志良(Chih-Liang Yaung)

勞工保險 ； 支付制度 ； 醫師行為 ； Labor insurance ； payment system ； physician behavior

中華公共衛生雜誌

13卷4期（1994 / 08 / 01）

315 - 329

繁體中文

全民健康保險預計於民國83年實施，政府將進一步干預醫療市場，加深對醫療供給與需求之影響。實施全民健康保險之國家，其健康保險之鉅額赤字常成為政府財政上沉重負擔；而醫療供給者對於醫療保險透過支付制度強制約束醫療行為與計算醫療報酬方式，常持反對態度。茲探討甲乙丙表實施前復，勞保門診醫療費用支付制度，對醫療供給者診療行為之影響；並闡示醫療院所特性、病人及疾病特性，對醫療供給者診療行為之影響，以供全民健保現劃之參考。 本文以80年3月台問地區勞工保險局收受醫療院所申報之「勞工保險醫療給付門診就診單」為研究母全體。塞於實務上需要，採分層二階段系統集束隨機方法抽樣，共獲有效樣本5213件。其分析結果與70年之研究結果比較，主要香現如下： 1.醫療費用支出中，內服藥費比例降低。由於甲乙丙表實施後，診察費提高、藥事服務費明列、藥價依照進價申報等因素，使得內服藥費比例降低（70年42.5%、80年3月29.3%）。 2.平均每張處方所開藥品數仍偏高（70年4.13、80年3月4.74)。 3.抗生素重覆使用情形仍相當嚴重。醫療院所愈基層愈傾向使用較多抗生素與重覆使用抗生素（80年3月重覆使用抗生素1種及以上之比例，基層醫療院所55.3%，醫學中心13.1%）。 4.大型醫療院所檢查費、X光診斷費比例偏高。 5.同一傷病之醫療費用變異，在一般申報與專案中報兩部份中，其解釋因素不同。一般申報方面，病人年齡、性別對費用變異均不具解釋能力；而專案中報方面，病人年齡、性別對費用變異卻具較強之解譯能力。 6.大型醫療院所傾向於治療慢性、複雜之傷病，而小型醫療院所則傾向於治療急性、簡單之傷病。

We randomly sampled 5, 213 outpatient medical records submitted by hospitals and clinics to the Bureau of Labor Insurance for reimbursement in March 1991 for this study. In 1990, the fee schedule, or the so-called ”point system” of reimbursement was drastically changed in which the physician fee rate increased and surcharge was not allowed for the costs of drugs. The case mix, the structure of expenses, and medical care behaviors of hospitals and clinics were analysed; the results were compared with those of 1981. The major findings are as follows: (1) The proportion of expenses of drugs for oral administration reduced from 42.5% (1981) to 29.3% (1991). (2) The drug intensity rate (DIR) among prescriptions kept high from 4.13 (1981) to 4.74 (1991). (3) The proportion of over prescription of antibiotics was prevalent in 1991, e.g. 55.3% with one or more antibiotics among prescriptions from cilinics, 13.1% with those among prescriptions form medical centers. (4) The proportion of expenses for laboratory tests and X-ray examinations increased, especially among those of medical centers. (5) The patients' age and sex explained much more cost variations in general applications than in special applications under the same disease type. (6) Medical centers tended to take care of more patients with chronic diseases than those primary medical care units did.