新增醫事服務申報模式以確保及提昇健保醫療品質

Abstract

自1995年實施健保以來，全民健保支出平均每年以超過8％的速度快速成長。在醫療支出飛漲的壓力下，健保局於1999年推行牙醫總額，2000年施行中醫總額，2001和2002年實施西醫基層和醫院總額，2003更進一步實施洗腎總額。這些總額制度的施行，將健保費用的財務風險由健保局轉向醫療供給者，有效的將醫療支出控制於總額施行前的一半，僅約4％。然而，在醫療費用成長空間受限下，卻傳出許多供給者以降低醫療服務的方式削減支出，造成消費者醫療品質降低，形成醫療供給者、消費者、以及健保局三方均輸的情境。要妥善瞭解總額制度對醫療服務的影響，最重要前提在於有效掌握供給者所提供的醫療品質。雖說健保局在歷年努力下已提供許多品質指標，可惜的是，這些指標多是從醫療利用上著手，較少從病人本身健康角度來建立醫療品質指標，造成許多研究者質疑這些醫療指標是否合理；其次，健保資料無法有效掌握病人就診前健康狀況，也造成分析醫療品質的一大難題。在這兩個前提上，本計畫預定從三個方向著手，改善現有的醫療品質指標。首先，以其他先進國家（如美國、英國、加拿大）為藍圖，瞭解這些國家如何妥善分析醫療品質，並選擇台灣合適指標；其次，由於台灣自健保實施以來已建立相當豐富而完整的健保資料庫，在資料允許範圍內，將可直接將總額實施後醫療品質的變化呈現；最後，若資料不允許，但卻是一個重要品質指標，則討論應採用何種方式將這些品質指標納入健保資料。 Since the inauguration of National Health Insurance (NHI) in 1995, the annual insurance expenditure has grown at a rate over 8%. In response to the rising expenditure, burea of national health insurance (BNHI) implements global budgeting on dental care in 1999, Chinese medicine in 1999, clinical and hospital care in 2001 and 2002, as well as dialysis care in 2003. The global budgeting system shifts financial risks from BNHI to health providers, effectively controlling the expenditure growth around 4% annually, almost half of the rate prior to the change of reimbursed practice. Because global budgeting limits the cap of health expenditure, many researchers suspect that providers supply health care at the cost of treatment quality, resulting in the welfare loss among BNHI, consumers, and health providers. To examine the impact of global budgeting on health services, it is essential for BNHI to empower with the ability of monitoring the quality of medical services. Although BNHI has established many quality indicators over years, these indicators are mostly concentrated on the area of medical utilizations, rather than that of treatment outcomes. In addition, the current national health insurance data do not provide enough information to effectively control patients’ health status prior to treatment; both leads researchers to question the validity of these quality indicators. This project aims to help BNHI to monitor health quality in three ways. First, based on experiences from other developed countries (U. S., U. K., or Canada), we can learn how they monitor the quality of care and select suitable quality indicators for Taiwan. Next, using the abundant insurance data that have been collected since 1997, we aim to show the change of quality of care due to global budgeting. Finally, if current insurance data not allowed, we plan to discuss how we could construct and incorporate important quality indicators into the insurance data in the future.