張睿詒Chang, Ray-E臺灣大學:醫療機構管理研究所吳佳穎Wu, Chia-YingChia-YingWu2010-05-052018-06-292010-05-052018-06-292008U0001-2907200810143400http://ntur.lib.ntu.edu.tw//handle/246246/180765健保局於民國90年7月實施西醫基層總額預算制度，期望藉由預先設定總額預算的方式，並藉由同儕制約促進合理醫療服務價量的提供，以有效控制醫療費用。支付制度的介入及改變會影響醫療提供者的醫療行為，進而影響醫療資源耗用的情形。而透析服務屬高服務量及高單價之醫療服務項目，且成長快速，並於各總額預算的分配架構中被獨立編列預算，故本研究旨在探討西醫基層總額預算制度下，門診透析總額對基層院所腎臟專科醫師執業行為的影響。研究為一自然實驗(natural experiment)，以1999年7月至2002年6月間，具腎臟專科執照且曾執行透析服務醫師為研究對象，將以專屬於基層院所醫師為實驗組，地區醫院醫師為對照組，採用差異中之差異法與GEE估計迴歸模型之統計方法，運用全民健康保險研究資料庫進行分析，以釐清西醫基層總額預算制度對基層院所腎臟專科醫師行為的影響。研究主要研究結論如下：1) 西醫基層總額預算制度實施前，相較於地區醫院，基層院所腎臟專科醫師可能存在預期心理，提前增加門診透析服務的醫療費用點數且顯著成長，顯示總額預期效應確實存在。2) 相較於地區醫院，西醫基層總額預算制度實施後，總額效應對基層診所腎臟專科醫師透析服務，有正向的影響，但不顯著，可能受限於研究上的限制，導致無法確認此效應。合上述，本研究建議衛生主管機關在新政策實施前後，需考量醫療提供者對政策介入的預期心理，及政策實施後醫師行為的改變，可預先擬定管理策略，俾使確保政策目標有效達成，並降低其他不欲見之次效應。Background：National Health Insurance implemented the global budget for primary care since July 2001. With expectations of the pre-set amount of budget caps and the mechanism of peer review to promote the reasonable price of medical services provided, and effective control medical costs. It is widely accepted that payment will affect how physicians practice medicine, thereby affecting consumption of medical resources. Dialysis care is a high-volume, high-priced medical service, and the number of patient requiring dialysis increase rapidly. Besides, the budget allocation framework of the provision was an independent budget.bjective：The purpose of this study is to investigate the impacts of outpatient dialysis global budgets on nephrologist behavior.ethods：This research is a natural experiment. The study subjects are licensed nephrologists who had practiced dialysis services from July 1999 to June 2002. Using National Health Insurance Research database for research, the nephrologists practicing in clinics are the experimental group, and the nephrologists in district hospitals are the control group. Adopting the differences-in-differences method and generalized estimation equation approach, the impacts of outpatient dialysis global budgets on nephrologist behavior were analyzed.indings:. Compared to the nephrologists of district hospitals, prior to the implementation of outpatient dialysis global budgets, the nephrologists of clinics may have anticipations effect and therefore increase outpatient dialysis services in advance. Medical expenses also increase significantly. . Compared to the nephrologists of district hospitals, after the implementation of outpatient dialysis global budgets, the global budgets of dialysis services have positively affected the services provided by nephrologists. he results suggested that the health administration should develop management strategies in advance in order to reduce expectation effects and adverse policy effects before a policy is implemented.口試委員會審定書致謝...................................................................................................I謝................................................................................................................................ II文摘要........................................................................................................................IIIBSTRACT ..................................................................................................................IV錄................................................................................................................................VI目錄.........................................................................................................................VIII目錄............................................................................................................................IX一章 緒論.................................................................................................................... 1一節 研究背景與動機............................................................................................. 1二節 研究目的......................................................................................................... 4二章 文獻探討............................................................................................................ 5一節 國內外末期腎臟病現況................................................................................. 5二節 全民健康保險透析服務支付制度之沿革................................................... 10三節 支付制度之財務誘因對醫師行為的影響................................................... 14四節 總額預算制度對醫師行為的影響之實證研究........................................... 19五節 國內總額制度對透析服務之影響............................................................... 22三章 研究方法.......................................................................................................... 23一節 研究設計與研究架構................................................................................... 23二節 研究假說....................................................................................................... 28三節 研究變項....................................................................................................... 29四節 研究材料與資料處理................................................................................... 30五節 統計方法....................................................................................................... 33四章 研究結果.......................................................................................................... 36一節 腎臟專科醫師特質....................................................................................... 36二節 腎臟專科醫師西醫門診服務之趨勢分析................................................... 38三節 腎臟專科醫師西醫門診執業服務之差異中的差異法分析....................... 40四節 腎臟專科醫師西醫門診執業服務之迴歸分析........................................... 42五節 研究結果小結............................................................................................... 46五章 討論.................................................................................................................. 47一節 研究結果討論............................................................................................... 47二節 研究限制....................................................................................................... 50六章 結論與建議...................................................................................................... 52考文獻........................................................................................................................ 54文部份.................................................................................................................... 54文部份.................................................................................................................... 57錄................................................................................................................................ 59目錄2-1-1 1999-2006 年國內透析病人數統計表............................................................. 62-1-2 1999-2005 年美國腎臟資料登錄系統各國ESRD 統計................................. 72-1-3 我國透析醫療費用2001-2007 年統計整理.................................................... 82-1-4 洗腎病患之重大傷病費用1999-2006 年統計................................................ 92-1-5 國內透析醫療供給1999-2006 年統計整理.................................................... 93-3-1 研究變項之操作型定義................................................................................. 294-1-1 實驗組與對照組腎臟專科醫師之基本資料................................................. 374-2-1 平均每位醫師西醫門診服務醫療費用點數................................................. 394-3-1 腎臟專科醫師西醫門診執業服務之差異中的差異法分析......................... 414-4-1 腎臟專科醫師西醫門診執業服務之迴歸分析─總額預期效應................. 444-4-2 腎臟專科醫師西醫門診執業服務之迴歸分析─總額效應......................... 454-5-1 各期間之差異中的差異................................................................................. 46目錄3-1-1 研究設計......................................................................................................... 253-1-2 研究架構......................................................................................................... 273-4-1 腎臟專科醫師樣本選取流程......................................................................... 323-5-1 研究期間各效應分析圖................................................................................. 344-2-1 腎臟專科醫師透析服務醫療費用點數......................................................... 39application/pdf1097601 bytesapplication/pdfen-US西醫基層總額預算制度門診透析服務醫師行為global budgetdialysis servicesphysician behaviorthesishttp://ntur.lib.ntu.edu.tw/bitstream/246246/180765/1/ntu-97-R95843013-1.pdf