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明天過後-健保支付制度的未來總額支付制度下醫院服務行為因應之實證研究明天過後明天過後:請問何謂總額支付請問何謂總額支付?健保法規定:總額支付九十一年七月全國不分區總額九十二年因SARS影響全年單一點值結算九十三年第二季起分區分門住診結算但是參加醫院卓越計畫者固定點值結算九十四年各分局自行操作門住診分開結算年年難過年年過!健保局還會有什麼花招?Global Budget 的理論與實務的理論與實務許多 OECD 國家採用 global budget 控制全部或部分醫療費用 實證經驗上global budgets 確實有效控制醫療費用的成長U.S.General Accounting Office 證明在法國與德國 global budgets 確實減少 9-17%的醫療支出 但是在全民健保或公辦的健保方面大部分國家也出現了需多醫療資源耗用的無效率化之問題 Table1.Characteristics of Global Budgeting Schemes Used in Table1.Characteristics of Global Budgeting Schemes Used in Organization for Economic Cooperation and Development CountriesOrganization for Economic Cooperation and Development CountriesCountryCountryProvider Type Provider Type ExpenditurExpenditure Typee TypeService TypeService TypeBudget Budget ProcessProcessAction if Action if Budget Budget ExceededExceededFinancing Financing Source Source GeographiGeographic Specificsc SpecificsAustralia Australia Public Public hospitals hospitals Operating Operating costscostsState-State-controlledcontrolledRise in private Rise in private patient patient revenues revenues decreases decreases State-funded State-funded revenuesrevenuesState tax State tax revenues and revenues and Federal Federal grantsgrantsState-State-specificspecificBelgium Belgium Teaching Teaching hospital hospital Operating Operating and capital and capital costscostsMagnetic Magnetic resonance resonance imagingimagingSickness-Sickness-fund-defined fund-defined global global budgeting budgeting for magnetic for magnetic resonance resonance imaging imaging amortization,amortization,operating operating costs,and costs,and radiologist radiologist feefeeNo additional No additional fundsfundsSocial Social Security Security contributions,contributions,State State subsidies.subsidies.NANAPharmaceuticPharmaceutical companiesal companiesprescriptionsprescriptionsSickness Sickness fund sets fund sets cap on drug cap on drug consumptionconsumptionIf consumption If consumption exceeds exceeds estimated estimated level,unit level,unit prices are prices are reduced reduced NANANANASee footnotes at end of tableTable1.-continued Characteristics of Global Budgeting Schemes Used in Table1.-continued Characteristics of Global Budgeting Schemes Used in Organization for Economic Cooperation and Development CountriesOrganization for Economic Cooperation and Development CountriesCountryCountryProvider Provider Type Type ExpenditurExpenditure Typee TypeService Service TypeTypeBudget Budget ProcessProcessAction if Action if Budget Budget ExceededExceededFinancing Financing Source Source Geographic Geographic SpecificsSpecificsCanada Canada Physicians Physicians Ambulatory Ambulatory carecareNegotiation Negotiation Fees Fees reduced reduced following following yearyearNational and National and provincial provincial tax revenuestax revenuesProvince-Province-specificspecificHospital Hospital Operating Operating Negotiation Negotiation Government Government maintains maintains small small emergency emergency budgeting budgeting overrunsoverrunsSame Same Province-Province-specific specific Finland Finland Hospital/Hospital/clinicsclinicsOperating Operating costs costs Multiple Multiple review review process process NANANational tax National tax revenuesrevenuesProvince-Province-specific specific France France Public Public hospitalshospitalsOperating Operating and debt and debt service service costs for costs for constructiconstruction and on and high-cost high-cost equipmentequipmentNationwide Nationwide hospital hospital target guides target guides negotiation negotiation between between hospital,hospital,found,and found,and governmentgovernmentSmall Small regional regional“maneuverin“maneuvering margin”g margin”Payroll tax;Payroll tax;hospitals hospitals paid in paid in monthly monthly installments installments Regional Regional See footnotes at end of tableTable1.-continued Characteristics of Global Budgeting Schemes Used in Table1.-continued Characteristics of Global Budgeting Schemes Used in Organization for Economic Cooperation and Development CountriesOrganization for Economic Cooperation and Development CountriesCountryCountryProvider Provider Type Type Expenditure Expenditure TypeTypeService Service TypeTypeBudget Budget ProcessProcessAction if Action if Budget Budget ExceededExceededFinancing Financing Source Source Geographic Geographic SpecificsSpecificsGermanyGermany1 1Physicians Physicians AmbulatorAmbulatory care y care Negotiation Negotiation between between sickness sickness fund fund associationassociations and s and physician physician association association NANAPayroll Payroll taxes,paid taxes,paid to physician to physician associations,associations,which which distribute to distribute to physicians physicians Regional Regional Netherland Netherland Hospital Hospital Operating Operating and some and some capital capital costscostsInventory Inventory and and equipment equipment only only Negotiation Negotiation between between hospital hospital and and sickness sickness funds funds None None Payroll tax,Payroll tax,premiums,premiums,catastrophic catastrophic fundfundNANASweden Sweden Hospital Hospital Operating Operating costscostsNegotiation Negotiation NANACountry and Country and national national taxestaxesCountry-Country-specificspecificSwitzerland Switzerland Hospital Hospital Operating Operating costscostsNegotiation Negotiation NANAFederal Federal Government Government Canton of Canton of Vaud onlyVaud onlyUnited United KingdomKingdomHospital Hospital and and physician physician Operating Operating and capital and capital costs costs All,All,including including prescriptioprescription drugn drugSet by the Set by the Ministry of Ministry of HealthHealthNo excess No excess foundfoundGeneral tax General tax revenuesrevenuesImplemented Implemented through 200 through 200 district Health district Health AuthoritiesAuthorities1 As of September 1991,the substitute funds removed expenditure caps on expenditures for physician services.Note:NA is not applicable SOURCE:Wolfe and Moran,Lewin-VHI,Fairfax,VA,1992.Table2.國際比較-醫療費用年平均成長率 西元年西元年西元年西元年國家國家國家國家1960-1960-197019701970-1970-198019801980-1980-199019901990-1990-201920192019-2019-201920192019-2019-201920192019-2019-201920192019-2019-201920192019-2019-200020002000-2000-201920192019-2019-201920192019-2019-201920192019-2019-20192019 澳澳洲洲澳澳洲洲 8.08.06.56.56.46.45.95.96.46.47.17.16.66.69.69.6 加加 拿拿 大大加加 拿拿 大大12.212.212.412.49.39.33.43.4-1.2-1.24.34.36.86.82.42.43.83.87.57.55.45.45.35.33.83.8 法法國國法法國國12.912.915.015.08.68.64.44.43.33.33.03.03.03.02.42.45.05.06.26.26.26.25.55.5 德德國國德德國國14.514.56.26.27.47.46.56.51.21.21.61.62.32.34.64.63.63.64.54.52.62.6 義義 大大 利利義義 大大 利利4.24.24.64.65.85.83.83.82.02.010.410.44.94.95.05.01.61.68.88.8 日日本本日日本本9.99.94.44.46.36.37.37.38.08.06.76.74.74.7 韓韓國國韓韓國國10.810.816.216.211.511.54.84.819.319.31.81.824.824.83.83.810.410.4 荷荷蘭蘭荷荷蘭蘭6.76.74.04.03.83.83.93.9-2.7-2.74.74.76.16.113.713.712.312.37.47.4 挪挪威威挪挪威威8.28.28.68.613.813.87.87.810.710.710.510.57.37.310.910.95.65.61.61.6 美美國國美美國國11.111.113.713.711.011.06.16.14.84.84.74.74.54.54.24.25.75.78.28.28.18.17.07.0 台台灣灣台台灣灣(全全 民民 健健 保保全全 民民 健健 保保)11.611.68.18.12.62.67.07.07.47.44.44.44.24.22019-2019年台灣(全民健保)醫療費用年成長率為4.0%。Table3.國際比較-每人年西醫門診次數 西元年西元年國家國家196019601970197019801980199019902019201920192019201920192019201920002000201920192019201920192019 澳洲澳洲 2.72.73.13.14.04.06.16.16.86.86.76.76.66.66.56.56.46.46.46.46.26.26.06.0 加 拿 大加 拿 大5.65.66.76.76.46.46.46.46.46.46.46.46.36.36.26.2 法國法國4.24.25.95.96.56.56.46.46.66.66.66.66.96.96.96.96.96.9 德國德國6.76.76.96.97.17.17.27.27.37.3 義 大 利義 大 利6.06.06.16.1 日本日本13.813.814.814.814.314.314.514.514.514.514.414.414.514.514.114.1 韓國韓國8.88.810.610.6 荷蘭荷蘭4.94.95.55.55.45.45.95.95.65.65.85.85.95.95.85.85.65.6 紐 西 蘭紐 西 蘭3.73.74.44.43.23.2 英國英國5.25.26.16.16.16.15.45.45.45.44.94.95.65.65.25.2 美國美國10.010.010.110.110.410.48.98.99.09.08.98.98.98.9 台灣台灣(全 民 健 保全 民 健 保)10.310.311.211.211.911.912.212.211.811.811.611.611.711.711.411.42019、2019年台灣(全民健保)平均每人西醫門診次數分別為12.3次及12.4次。Table4.Table4.國際比較國際比較-每人國民醫療保健支出年平均成長率每人國民醫療保健支出年平均成長率 西元年西元年國家國家1960-1960-197019701970-1970-198019801980-1980-199019901990-1990-201920192019-2019-201920192019-2019-201920192019-2019-201920192019-2019-201920192019-2019-200020002000-2000-201920192019-2019-201920192019-2019-20192019 澳洲澳洲 6.66.66.06.05.95.95.65.66.56.56.86.88.28.24.94.97.17.1 加 拿 大加 拿 大9.19.110.310.38.38.33.43.40.10.14.14.17.57.54.44.44.34.38.38.34.94.95.65.6 法國法國11.611.613.013.08.28.25.35.33.13.13.03.03.53.53.43.46.26.26.66.65.55.55.15.1 德國德國13.613.66.16.15.45.46.16.10.40.42.42.43.03.04.44.44.24.24.84.82.72.7 義 大 利義 大 利2.02.05.55.56.06.05.25.23.13.110.110.15.15.14.44.40.40.4 日本日本17.517.514.514.56.86.86.66.67.27.22.52.53.23.24.94.97.87.86.16.12.32.3 韓國韓國7.47.412.412.44.64.6-2.5-2.518.318.35.85.820.920.94.54.510.210.2 荷蘭荷蘭6.66.64.94.93.23.22.52.55.85.84.44.45.85.811.511.510.110.17.27.2 紐 西 蘭紐 西 蘭9.29.27.07.04.64.62.02.06.66.66.86.85.05.05.45.46.06.08.88.82 2 挪威挪威11.111.116.816.87.77.76.36.39.29.213.513.58.38.310.610.69.59.56.66.610.010.05.35.3 英國英國6.86.811.411.47.47.46.96.95.75.73.83.84.64.67.17.18.58.510.910.99.89.8 美國美國9.29.211.811.810.010.05.95.93.83.83.93.94.04.04.84.85.75.77.77.78.28.26.66.6 台灣台灣(全 民 健 保全 民 健 保)10.410.47.57.57.97.97.17.13.33.32.82.83.33.34.04.02019-2019年台灣每人國民醫療保健支出年成長率為3.53%。總額支付的功與過從結果論:確實把醫療費用控制下來了但是各國做法不同Waiting List問題相同是資源利用的效率問題嗎?-付費者的觀點或是資源投入的不足呢?-醫療提供者的觀點何謂資源耗用的效率節約醫療費用並不等於達到效率效率 efficiency.static efficiency,靜態的效率 代表 改善了金錢使用的價值dynamic efficiency,動態的效率 以有限的人力或醫師資源不斷改進醫療及技術以提升機構的生產力 W.P.M.M.Van de Ven in his study“Micro-economic efficiencyW.P.M.M.Van de Ven in his study“Micro-economic efficiency如何證明資源投入不足?或使用不具效率?全國醫院總額全區醫院總額個別醫院總額門診總額與住院總額上述何者較佳?國際間global budget實證比較的困難各國間實施總額支付的結構方法與效果各不相同主要原因是各國的社會福利制度與文化差異另一方面是 global budgeting schemes 是用於改善醫療費用上漲與醫療給付範圍的工具各國之間缺乏比較基礎研究目的值得借鏡的台灣經驗個別醫院總額或區域總額的政策選擇 什麼醫院偏好個別醫院總額?什麼醫院偏好區域總額?全國一個總額好嗎?不同總額支付下院醫療服務提供行為?如何解決總額制度下的效率問題?台灣總額支付制度將如何發展?研究方法Data sourcelongitudinal hospital-level panel data on outpatient and inpatient services for a period of 48 months,from 2019 to 2019,from the BNHIs medical-claim payment submission data bank.The exclusion criteria for hospitals in the study were as followings:(1)hospitals that provided outpatient care only during the study period,(2)hospitals that did not have a complete medical-claim payment submission during the 48 months.The hospitals finally included in our study were 448.GBI group and the GBT groupThe 448 hospitals were divided into GBI group and the GBT group.Because the wide deference of size and scale of services provided,all of the 448 hospitals were subdivided into medical centers(500 plus beds),regional hospitals(250-500 beds)or district hospitals(20-250 beds)for further comparison and analysis.For the varying scale of district hospitals we classified in advance according to their beds into hospital with less than 49 beds,50-99 beds,and more than 100 beds.Time fixed group effects For the 48 months hospital-level panel data we sum up For the 48 months hospital-level panel data we sum up the monthly claim data into 16 consecutive quarterly the monthly claim data into 16 consecutive quarterly data.data.In our study,we took the first quarter(Q1)of 2019 as a In our study,we took the first quarter(Q1)of 2019 as a fixed standard reference for comparing with each quarter fixed standard reference for comparing with each quarter of 2019 to 2019 to observe the time fixed trend effects.of 2019 to 2019 to observe the time fixed trend effects.And for every quarter we took all hospitals in the same And for every quarter we took all hospitals in the same group as a whole to observe the group effects.group as a whole to observe the group effects.The growth rates of quantities and qualities of healthcare The growth rates of quantities and qualities of healthcare provided of the 15 consecutive quarters after Q1 of 2019 provided of the 15 consecutive quarters after Q1 of 2019 were calculated as:(Qn Q1 of 2019)/Q1 of 2019;were calculated as:(Qn Q1 of 2019)/Q1 of 2019;where n=2 to 15.where n=2 to 15.Then we plotted the growth rates as time trends to Then we plotted the growth rates as time trends to observe the changes of coping behaviors of the two observe the changes of coping behaviors of the two different payment schemes.different payment schemes.結果Characteristics of hospitals among different payment schemesTime fixed group effects of outpatient visit Time fixed group effects of inpatient services 參加與不參加卓越計畫之醫院參加與不參加卓越計畫之醫院，有何分局別層級別權屬別或管理有何分局別層級別權屬別或管理上之特質上之特質？表1.醫院卓越計畫參加(GBI)與不參加醫院(GBT)依層級別比較家數佔率及費用佔率層級別層級別參加參加 N(%)N(%)不參加不參加 N(%)N(%)總計總計(N)(N)醫學中心醫學中心1313(72.2)(72.2)81.6%81.6%5 5(27.8)(27.8)18.4%18.4%1818區域醫院區域醫院3232(46.4)(46.4)50.6%50.6%3737(53.6)(53.6)49.4%49.4%6969地區醫院地區醫院149149(41.3)(41.3)44.3%44.3%212212(58.7)(58.7)55.7%55.7%361361 50=100=100床床4141(43.6)(43.6)39.6%39.6%5353(56.4)(56.4)60.4%60.4%9494總計總計194194(43.3)(43.3)62.7%62.7%254254(56.7)(56.7)37.3%37.3%448*448*():家數佔率:費用佔率*91年94年醫院資料檔中,4年都有資料之醫院數 表2.醫院卓越計畫參加(GBI)與不參加(GBT)醫院依分局別比較家數佔率及費用佔率分局別分局別參加參加 N(%)N(%)不參加不參加 N(%)N(%)總計總計(N)(N)台北分局台北分局4949(48.0)(48.0)77.9%77.9%5353(52.0)(52.0)22.1%22.1%102102北區分局北區分局 2222(42.3)(42.3)67.8%67.8%3030(57.7)(57.7)32.2%32.2%5252中區分局中區分局 4545(52.9)(52.9)60.1%60.1%4040(47.1)(47.1)39.9%39.9%8585南區分局南區分局 1717(22.4)(22.4)63.6%63.6%5959(77.6)(77.6)36.4%36.4%7676高屏分局高屏分局 5454(45.8)(45.8)37.3%37.3%6464(54.2)(54.2)62.7%62.7%118118東區分局東區分局7 7(46.7)(46.7)34.8%34.8%8 8(53.3)(53.3)65.2%65.2%1515總計總計194194(43.3)(43.3)62.7%62.7%254254(56.7)(56.7)37.3%37.3%448*448*():家數佔率:費用佔率*91年94年醫院資料檔中,4年都有資料之醫院數表表3.3.醫院卓越計畫參加醫院卓越計畫參加(GBI)(GBI)與不參加與不參加(GBT)(GBT)醫院依醫院依權屬別比較家數佔率及費用佔率權屬別比較家數佔率及費用佔率 權屬別權屬別參加參加 N(%)N(%)不參加不參加 N(%)N(%)總計總計 (N)(N)公立醫院公立醫院2424(31.6)(31.6)59.0%59.0%5252(68.4)(68.4)41.0%41.0%7676私立醫院私立醫院128128(43.2)(43.2)52.6%52.6%168168(56.8)(56.8)47.4%47.4%296296財團法人及財團法人及法人附設醫法人附設醫院院4242(55.3)(55.3)69.1%69.1%3434(44.7)(44.7)30.9%30.9%7676總計總計194194(43.3)(43.3)62.7%62.7%254254(56.7)(56.7)37.3%37.3%448*448*():家數佔率:費用佔率*91年94年醫院資料檔中,4年都有資料之醫院數 參加與不參加醫院卓越計畫之醫院，於計劃介入年後與介入前一年，其總額預算在門住診部門之別配置是否有變化？表5.卓越計畫實施後一年各層級別介入前後之成長率參加參加不參加不參加介入前介入前1 1成長率成長率介入後介入後2 2成長率成長率介入前介入前1 1成長率成長率介入後介入後2 2成長率成長率醫學中心醫學中心(N=13)(N=13)(N=5)(N=5)門診件數門診件數-1.2%-1.2%-8.6%-8.6%2.7%2.7%5.8%5.8%門診點數門診點數6.4%6.4%-5.1%-5.1%10.6%10.6%9.3%9.3%住院件數住院件數-3.0%-3.0%2.2%2.2%4.8%4.8%3.2%3.2%住院點數住院點數4.7%4.7%7.6%7.6%11.5%11.5%6.9%6.9%急診件數急診件數-3.9%-3.9%7.1%7.1%6.2%6.2%36.8%36.8%急診點數急診點數8.2%8.2%0.8%0.8%7.7%7.7%34.3%34.3%區域醫院區域醫院(N=32)(N=32)(N=37)(N=37)門診件數門診件數-1.1%-1.1%-1.6%-1.6%8.5%8.5%12.7%12.7%門診點數門診點數8.4%8.4%-4.3%-4.3%18.0%18.0%14.6%14.6%住院件數住院件數-2.2%-2.2%-0.1%-0.1%3.0%3.0%8.0%8.0%住院點數住院點數8.5%8.5%5.3%5.3%18.9%18.9%12.4%12.4%急診件數急診件數0.8%0.8%5.9%5.9%5.7%5.7%9.6%9.6%急診點數急診點數17.5%17.5%3.5%3.5%26.0%26.0%11.2%11.2%註1：介入前成長率=（92年第四季-91年第四季）/91年第四季資料註2：介入後成長率=（93年第四季-92年第四季）/92年第四季資料 表表6-1.6-1.卓越計畫實施後一年地區醫院以床數分組各組介入前後之成長率卓越計畫實施後一年地區醫院以床數分組各組介入前後之成長率 參加參加不參加不參加介入前介入前1 1成長率成長率介入後介入後2 2成長率成長率介入前介入前1 1成長率成長率介入後介入後2 2成長率成長率地區醫院地區醫院(N=149)(N=149)(N=212)(N=212)門診件數門診件數2.2%2.2%-7.1%-7.1%2.4%2.4%14.4%14.4%門診點數門診點數10.0%10.0%-7.6%-7.6%10.2%10.2%20.6%20.6%住院件數住院件數-5.9%-5.9%-4.1%-4.1%-0.7%-0.7%6.6%6.6%住院點數住院點數10.7%10.7%1.7%1.7%16.3%16.3%20.8%20.8%急診件數急診件數4.0%4.0%-0.9%-0.9%7.3%7.3%10.8%10.8%急診點數急診點數15.0%15.0%8.4%8.4%16.7%16.7%20.6%20.6%地區醫院地區醫院=49=100=100床床(N=41,43.6%)(N=41,43.6%)(N=53,56.4%)(N=53,56.4%)門診件數門診件數2.4%2.4%-7.3%-7.3%1.9%1.9%24.8%24.8%門診點數門診點數12.1%12.1%-7.5%-7.5%11.3%11.3%30.0%30.0%住院件數住院件數-4.2%-4.2%-5.1%-5.1%2.0%2.0%11.0%11.0%住院點數住院點數8.5%8.5%2.8%2.8%16.0%16.0%24.5%24.5%急診件數急診件數5.3%5.3%8.6%8.6%10.8%10.8%14.6%14.6%急診點數急診點數18.1%18.1%15.8%15.8%21.0%21.0%22.6%22.6%註1：介入前成長率=（92年第四季-91年第四季）/91年第四季資料註2：介入後成長率=（93年第四季-92年第四季）/92年第四季資料 參加與不參加醫院卓越計劃之醫院，9194年間分配的總額是否呈現時間序列的變化？圖1.以91Q1為基準比較各門診指標的醫院群體成長趨勢時序變化門診平均每日看診人數成長率 門診平均每人次費用成長率 門診平均每人次藥費成長率 門診平均每人次檢驗檢查費用成長率 圖2-1.以91Q1為基準比較各住院指標的醫院群體成長趨勢時序變化住院平均每日住院人數成長率 住院平均每人次費用成長率 住院平均日數成長率(將=30天的住院天數刪除)住院每人每日費用成長率 圖2-2.以91Q1為基準比較各住院指標的醫院群體成長趨勢時序變化住院CMI值 住院天數=30天醫院家數參加醫院家數參加醫院家數不參加醫院家數不參加醫院家數總計總計醫學中心醫學中心0 01 11 1區域醫院區域醫院1 14 45 5地區醫院地區醫院=100=100床床9 914142323地區醫院地區醫院50-9950-99床床131326263939地區醫院地區醫院=49=100床參加與不參加醫院門診行為比較 門診平均每日看診人數成長率門診平均每人次費用成長率門診平均每人次藥費成長率門診平均每人次檢驗檢查費用成長率 圖6.地區醫院50-99床參加與不參加醫院門診行為比較 門診平均每日看診人數成長率門診平均每人次費用成長率門診平均每人次藥費成長率門診平均每人次檢驗檢查費用成長率 圖7.地區醫院=100床參加與不參加醫院住院行為比較 住院平均每日住院人數成長率 住院平均每人次費用成長率 住院平均日數成長率 住院每人每日費用成長率 圖9-2.地區醫院=100床參加與不參加醫院住院行為比較 住院CMI值 圖10-1.地區醫院50-99床參加與不參加醫院住院行為比較 住院平均每日住院人數成長率 住院平均每人次費用成長率 住院平均日數成長率 住院每人每日費用成長率 圖10-2.地區醫院50-99床參加與不參加醫院住院行為比較 住院CMI值 圖11-1.地區醫院=49床參加與不參加醫院住院行為比較 住院平均每日住院人數成長率 住院平均每人次費用成長率 住院平均日數成長率 住院每人每日費用成長率 圖11-2.地區醫院=49床參加與不參加醫院住院行為比較 住院CMI值 表表9.9.點值點值醫療支出年成長率醫療支出年成長率門診平均點值門診平均點值住院平均點值住院平均點值年平均核減率年平均核減率 門診初核門診初核住診初核住診初核201920195.15%5.15%Q3Q30.96140.96140.96140.9614Q4Q40.95220.95220.95220.9522201920194.41%4.41%0.90950.90950.99950.99952.32%2.32%2.49%2.49%Q1Q1Q2Q2Q3Q3Q4Q4201920194.53%4.53%3.36%3.36%2.73%2.73%Q1Q10.76770.76771.00711.0071Q2Q20.76010.76011.00711.0071Q3Q30.84360.84360.96190.9619Q4Q40.82960.82960.96740.9674201920194.68%4.68%4.40%4.40%4.31%4.31%Q1Q10.89200.89200.89200.8920Q2Q20.90800.90800.90800.9080Q3Q30.90080.90080.90080.9008Q4Q40.90010.90010.90010.9001201920194.90%4.90%結論台灣實施醫院部門總額後確實將每年醫療支出成長率控制在92年4.64%93年4.46%94年3.92%95年4.07%證明總額支付制度卻能有效控制醫療費用但與過去醫療費用年平均成長率87年11.6%88年 8.1%89年2.0%90年7.0%91年7.4%相比恐有醫療費用浥注不足的疑慮般大型醫院較傾向於參加GBI因為點值固定易於操作但是地區醫院中較大型者則為了向上提升多傾向選擇BGT表10.國際比較-醫療費用年平均成長率 西元年西元年國家國家1960-1960-197019701970-1970-198019801980-1980-199019901990-1990-201920192019-2019-201920192019-2019-201920192019-2019-201920192019-2019-201920192019-2019-200020002000-2000-201920192019-2019-201920192019-2019-201920192019-2019-20192019 澳洲澳洲 8.08.06.56.56.46.45.95.96.46.47.17.16.66.69.69.6 加 拿 大加 拿 大12.212.212.412.49.39.33.43.4-1.2-1.24.34.36.86.82.42.43.83.87.57.55.45.45.35.33.83.8 法國法國12.912.915.015.08.68.64.44.43.33.33.03.03.03.02.42.45.05.06.26.26.26.25.55.5 德國德國14.514.56.26.27.47.46.56.51.21.21.61.62.32.34.64.63.63.64.54.52.62.6 義 大 利義 大 利4.24.24.64.65.85.83.83.82.02.010.410.44.94.95.05.01.61.68.88.8 日本日本9.99.94.44.46.36.37.37.38.08.06.76.74.74.7 韓國韓國10.810.816.216.211.511.54.84.819.319.31.81.824.824.83.83.810.410.4 荷蘭荷蘭6.76.74.04.03.83.83.93.9-2.7-2.74.74.76.16.113.713.712.312.37.47.4 挪威挪威8.28.28.68.613.813.87.87.810.710.710.510.57.37.310.910.95.65.61.61.6 美國美國11.111.113.713.711.011.06.16.14.84.84.74.74.54.54.24.25.75.78.28.28.18.17.07.0 台灣台灣(全 民 健 保全 民 健 保)11.611.68.18.12.62.67.07.07.47.44.44.44.24.22019-2019年台灣(全民健保)醫療費用年成長率為4.0%。結論GBI醫院一般以減少服務量來應付為確保整體利潤則減少藥品單價增加檢驗檢查內容GBT醫院則為衝量以平衡點值與核減的風險在單價的策略上是採價量齊揚的對策GBT醫院在平均住院日數是採很獨特的增加策略結論總體而言 1.因為有GBI與 GBT 兩者在服務量上互補 對民眾就醫方便性上未產生明顯影響 2.門診價格策略與住院每日費用平均住院 日數明顯升高在病人結構不便疾病嚴重 度相似情形下顯示資源耗費的無效率性 3.45:55 的政策下沒有配套條件直接把預算切給住院以致增加GBI與GBT的無效率資源耗用是政策的結果建議錢跟著人走或是人跟著錢走?在現行FFS架構下健保局是採Competitive Regulation 還需要再加上Global Budget嗎?建議如果要!我們建議的Solutions:1.BGI比GBT更具有費用節制的功能 2.解決總額支付制度下效率的問題 a.個別醫院總額支付引進DRG和RVRBS 作為總額協商的調整因素 b.協商的總額支付醫院的Operation Cost 或Fix Cost 其他的變動成本則以DRG 支付 Thank you拯畏怖汾关炉烹霉躲渠早膘岸缅兰辆坐蔬光膊列板哮瞥疹傻俘源拯割宜跟三叉神经痛-治疗三叉神经痛-治疗
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