劉順仁臺灣大學：商學研究所碩士在職專班高階公共管理組邱献章Chiu, Hsien-JaneHsien-JaneChiu2007-12-032018-06-292007-12-032018-06-292007http://ntur.lib.ntu.edu.tw//handle/246246/63876Chinese Abstract 目的 : 本研究欲了解醫療給付制度的改變，是否會影響醫師的醫療行為。故以精神分裂症患者的治療為例，檢視在實施醫院總額制度後，精神科醫師開立第二代抗精神病藥物的形態是否發生變化。 方法 : 由健保局提供的2001至2004年歸人檔資料中，選出43386立精神分裂症患者。實施醫院總額預算對於醫療行為的影響可能產生延遲效應，所以我們設定總額制度實施半年後為分界點，即2004年1月，以一般線性迴歸方程模式檢視分界點前後各醫院使用第二代藥物的藥費與頻率的趨勢。並按醫院的性質，分成 : 醫學中心與精神專科醫院，公立與私立醫院，分別檢視上述第二代藥物使用的情形。 結果 : 整體趨勢而言，在方案介入之前，第二代藥物藥費及使用率上昇，到介入點之後，即呈現停滯，不再成長(p = 0.0004)。在介入點後，與醫學中心相較，專科醫院的第二代藥物使用情形較不受影響(p < 0.0001) ; 而與私立醫院相較，公立醫院的第二代藥物使用情形較不受影響(p < 0.019)。 結論 : 抗精神病藥物之使用形態在實施醫院總額制度後失去持續成長的趨勢，故用藥形態在介入點後有明顯的變化。另外，隨著醫院形態的不同，使用第二代藥物的形態也有差異。如 : 公立精神專科醫院的藥物使用形態，最不受影響。進一步的方向應再檢視公立精神科醫院的核心價值，並嘗試在未來的精神醫療長期照護領域，強化其服務品質; 另一方面，尋找其他影響醫師醫療行為的因子，並向醫療政策決定者提出建言，制定更好的醫療政策，以嘉惠病人。English Abstract Objective: To examine the impact of the implementation of hospital-based global budget programs upon the psychiatrists’ prescribing pattern of Second-Generation Antipsychotics (SGA). Methods: Data for this study were collected between 2001 and 2004 as part of the NHI database, which included exclusively patients with schizophrenia. For considering lagging effect of hospital-based global budget program upon the prescription behavior, we set a “dividing point” at January 2004, which is 6 months after the starting point of the implementation of global budget. We used general linear regression model to compare the trend of SGA use before and after the dividing point. Two indicators were calculated: proportions of SGA for drug expenditures and use frequency in outpatient and inpatient departments separately. Public sectors versus private sectors and psychiatric centers versus medical centers were examined respectively. The sample of this study consisted of 43386 individuals. Results: The proportions of SGA in outpatient departments for expenditures and use frequency predominantly increased after Sep, 2002 (starting point of relaxed regulation on SGA use). After the dividing point, SGA proportions in outpatient and inpatient departments did not show obvious growing pattern as they did before the starting point, but appeared to be at a staggering pace lasting for 12 months (p = 0.0004). Compared with medical centers, the SGA expenditures of the psychiatric centers were less affected after the dividing point (p < 0.0001); compared with private sectors, the SGA expenditures of public sectors were less affected after the dividing point (p < 0.019) Conclusions: We have revealed that psychiatrists’ prescribing pattern of antipsychotics is affected by the implementation of global budget programs; and the extent of influence varies by the types of hospitals, for example, public psychiatric centers are least affected by the implementation of global budget program. Further studies may engage in finding other factors affecting the psychiatrists’ behavior, and applying them on promoting the quality of life and mental-health care for those who are in need of psychiatric service.TABLE OF CONTENTS 口試委員審定書............................................i 致謝.....................................................ii Chinese Abstract........................................iii English Abstract.........................................iv Table of Contents........................................vi Index of Figures.......................................viii Index of Tables...........................................x Chapter1. Introduction....................................1 1.1 Incentives and financing methods regarding medical services..................................................2 1.2 Example of Global budget solution and physicians’ prescribing behavior......................................2 1.3 Medical policy and physicians’ medical behavior......3 1.4 Schizophrenia and Second Generation Antipsychotics(SGA).....................................................4 1.5 Factors related to decisions of prescribing SGA by psychiatrists.............................................5 1.6 Global budget in Taiwan...............................6 1.7 The adaptive behavior of the hospital to the implementation of hospital-based GB program...............6 1.8 The response of physicians’ behavior to the implementation of GB......................................7 1.9 The financial incentives among different types of hospitals and the influence of SGA-prescription pattern...7 Chapter2. Objectives......................................9 Chapter3. Hypothesis.....................................10 Chapter4. Methods........................................11 Chapter5. Results........................................13 5.1 Comparison of SGA-use trend before and after dividing point between medical centers and psychiatric centers....13 5.2 Public sectors versus private sectors................14 Chapter6. Discussions....................................15 6.1 Game theory: physicians versus hospital under hospital-based GB.................................................16 6.2 The significance of SGA use pattern in public psychiatric centers......................................17 6.3 Strength and limitation..............................19 Chapter7. Conclusions....................................22 Reference Materials......................................24 Index of Figures Figure 1. The trends of expenditures and revenues of NHI program in Taiwan (1995 -2005)...........................35 Figure 2. Time table of significant measures regarding national health insurance in Taiwan......................36 Figure 3. The examples of hospitals’ responses to hospital-based global budget.............................37 Figure 4. The possible impact of global budget and response to it on each level of medical service..........38 Figure 5. The algorithm of data selection, analysis and stratification...........................................39 Figure 6. The amount of psychiatric service between private sectors and public sectors.......................40 Figure 7. The amount of psychiatric service between medical centers and psychiatric centers..................41 Figure 8. The trend of proportions regarding SGA expenditures in outpatient departments...................42 Figure 9. The trend of SGA expenditures between medical centers and psychiatric centers in outpatient departments..............................................43 Figure 10. The trend of SGA-use frequency between medical centers and psychiatric centers in outpatient departments..............................................44 Figure 11. The trend of SGA expenditures between medical centers and psychiatric centers in inpatient departments..............................................45 Figure 12. The trend of SGA-use frequency between medical centers and psychiatric centers in inpatient departments..............................................46 Figure 13. The trend of SGA expenditures between private sectors and public sectors in outpatient departments.....47 Figure 14. The trend of SGA-use frequency between private sectors and public sectors in outpatient departments.....48 Figure 15. The trend of SGA expenditures between private sectors and public sectors in inpatient departments......49 Figure 16. The trend of SGA-use frequency between private sectors and public sectors in inpatient departments......50 Figure 17. The possible response mechanisms to global budget among various types of hospitals..................51 Figure 18. The distribution of beds among various types of hospitals................................................52 Index of Tables Table 1. The amount of psychiatric service between private sectors and public sectors.......................29 Table 2. The amount of psychiatric service between medical centers and psychiatric centers..................30 Table 3. Regression regarding the global trend of proportions for SGA expenditure in outpatient departments..............................................31 Table 4. Regression regarding the trends of proportions for SGA expenditures between medical centers and psychiatric centers......................................32 Table 5. Regression regarding the trends of proportions for SGA expenditures between public sectors and private sectors..................................................33 Table 6. Game theory: physicians versus hospitals under the global budget program................................345080687 bytesapplication/pdfen-US醫院總額預算制度醫師行為第二代抗精神病藥物精神分裂症hospital-based global budgetphysician behaviorsecond-generation antipsychotics (SGA)schizophreniaotherhttp://ntur.lib.ntu.edu.tw/bitstream/246246/63876/1/ntu-96-P94743014-1.pdf