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題 名 | Do Closed-system Hospitals Shift Care under Case Payment? Early Experiences Comparing Five Surgeries in Taiwan=封閉式醫院是否在前瞻性支付下移轉照護?臺灣五項手術的初期經驗 |
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作 者 | 文羽苹; 溫秀英; | 書刊名 | 長庚醫學 |
卷 期 | 31:1 2008.01-02[民97.01-02] |
頁 次 | 頁91-101 |
分類號 | 419.45 |
關鍵詞 | 前瞻性支付; 論病例計酬; 照護移轉; 封閉式醫院; 醫療資源利用; 臺灣; Prospective payment systems; PPS; Case payment; Care-shifting; Closed-system hospital; Health care utilization; Taiwan; |
語 文 | 英文(English) |
中文摘要 | 背景:近年來日本、韓國、臺灣的國民健康保險紛紛採用前瞻性支付制度(PPS)以節制醫療費用。美國Medicare實施Diagnosis-Related-Groups(DRGs)的經驗顯示:論病例計酬(CP)雖然縮減住院天數,但也產生移轉照護的誘因。本研究分析臺灣的封閉式醫院是否移轉照護以因應前瞻性支付的論病例計酬。 方法:樣本來自3家醫院5種手術的病患,共計22,327人,研究期間自1996年10月至1999年8月,論病例計酬則於1997年10月1日開始實施。重要依變項包括住院申報費用以及術前、術後病患門診次數與申報費用,以及術前、術後4週內的門診次數。控制變項包括年齡、性別、實施論病例計酬的時間、診斷和機構別。我們以Ordinary Least Square(OLS)分析每位病患住院、門診申報費用,以Poisson regressions分析門診次數。 結果:論病例計酬之後,平均住院日、住院總費用、住院X光與檢驗費用顯著下降;OLS估計CP第2年係數分別為-.86、-.06、-.15、-.04(p<0.01)。第2年手術前的門診費用平均較實施前高79%。考慮術前、術後4週內的門診和住院的總利用,即使有相當的照護移轉,論病例計酬仍然節省醫療的總利用約12%,不同醫院照護移轉的幅度有顯著差異。 結論:臺灣實施前瞻性支付5項手術的初期經驗顯示,論病例計酬節省醫療的總利用,並產生不同程度的術前照護移轉。 |
英文摘要 | Background: Recently, Japan, Korea, and Taiwan have adopted prospective payment systems (PPS) for healthcare. Experiences of the United States Medicare show that PPS reduces length of stay but creates incentives to shift care from regulated to un-regulated settings. In this study we investigated whether closed-system hospitals in Taiwan responded to case payment (CP) V one type of PPS, and if so, how this was managed. Methods: Data were derived from three Taiwanese hospitals for five different surgical procedures (N = 22,327). The study period covered from October 1996 through August 1999, with CP commencing on October 1, 1997. Important dependent variables included inpatient medical claims, outpatient medical claims, and number of outpatient visits. Outpatient utilization from the period four weeks prior to admission and four weeks following discharge were merged for each patient. Ordinary Least Square (OLS) and Poisson regression were used to test the studies shifting hypotheses, controlling for gender, age, patient diagnoses, and institution attended. Results: Length of hospital stay, amount of inpatient claims, and inpatient x-ray and lab-test claims were significantly reduced after CP. Corresponding OLS coefficients for the second year of implementation were, respectively, V.86, V.06, V.15, and V.04 (p < 0.01). Significant forward shifting of outpatient care, (79%), was found during the second year of CP. Despite the care-shifting effects noted herein, the average per-capita total claims reduced by 12%. Significant institutional effects were associated with the pattern of care-shifting. Conclusions: Our results indicate that CP reduced total claims for the selected surgical procedures, even under evident forward care-shifting. |
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