我國全民健康保險制度之實施，對成本控制與品質之影響

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張力(Li Chuang) 查詢紙本館藏

畢業系所

企業管理學系

論文名稱

我國全民健康保險制度之實施，對成本控制與品質之影響
(THE EFFECT OF COST CONTAINMENT AND QUALITY AFTER THE NATIONAL HEALTH INSURANCE SYSTEM IN TAIWAN)

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摘要(中)

成本控制與品質為醫療產業兩大指標，亦是國家重要之課題。台灣於1995年實行全民健保制度，期望能同時達成降低醫療成本與提升醫療品質之目標。惟許多文獻上皆認為醫療成本與醫療品質為正相關，也就是抵換原理(Trade-off) 。當醫療成本上升時將產生較佳之醫療品質。另外，在成本增加之時，是否有較佳之方法控制成本。
本研究以台北市立醫院為樣本，研究期間為1990年至2001年。實證研究發現實施健保後，醫院之死亡率較健保前降低，此意謂，於實施健保後醫療品質增加。但醫療成本卻比採行健保前顯著增加。成本之增加可能是健保局之監督系統失靈及健保支付制度採用論量計酬(Fee-for-service)有關，因為該制度會誘發浪費與超額之服務，而使醫療成本明顯增加。而醫療品質提升之原因，可能為健保制度增加健保特約醫院數，及病人可以自由選擇就醫之制度等，使醫院競爭增加，為了吸引病人而導致醫院提升其醫療品質。
由於醫療成本增加將造成健保制度破產，本研究進一步找尋，增加醫院成本之相關因子，期望從成本因子找出控制之方法。發現實行健保增加全民健保覆蓋率(老年人口比率與特殊疾病)及增加特約醫院數(平均住院天數與新技術之醫療設備)等增加成本之因子為直接受健保制度所影響。所以政府應採行預防醫療相關制度(Health prevention activities)與疾病管理制度(Disease management programs)，以減少老人所造成之醫療成本之增加。此外，醫院應該增加醫療效率，降低平均住院天數，更應該找到醫院之市場定位，從而購買適合該定位之新醫療設備，成為該領域之領導者非追隨者。最後，醫療法令制定者應從增加成本之因子中設定各醫院之成本標竿(Bench-mark)，迫使醫院遵循此標竿，以達到降低國家整體醫療成本之目標。

摘要(英)

Taiwan implemented the National Health Insurance system (NHI) in 1995. However, after the NHI, the insurance coverage expanded and competition increased, whether the cost containment and quality are improved. The main purpose of this study was to examine the dynamic change in cost containment and quality under the National Health Insurance (NHI) program in Taiwan. Moreover, the objective of this study is to determine what factors have direct impact on the increased costs after the NHI.
Panel data analysis is used to investigate changes and factors affecting cost containment at Taipei municipal hospitals from 1990 to 2001. The findings show that the current monitoring system does not help to improve cost containment after the implementation of the NHI. Indeed, the fee-for-service system of the NHI has led to healthcare resource waste – poor cost containment. Additionally, the increasingly competitive market (increased number of contractual hospitals and freedom to choose hospitals policy) has led to a better healthcare quality. This implies that healthcare policies can only improve either quality or cost separately; the monitoring system of BNHI only could improve quality, but not cost containment. Furthermore, the results indicate that the expansion of insured healthcare coverage (especially to the elderly and the treatment of more complicated types of diseases), and the increased competition (requiring the growth of new technology and the longer average length of stay) are important driving forces behind the increase of hospital costs, directly influenced by the advent of the NHI.
Therefore, policymakers should emphasize health prevention activities and disease management programs for the elderly to improve cost containment. Additionally, hospital managers should find ways to improve the hospital efficiency (shorten the LOS) to reduce excess services and medical waste. They also need to better understand their market position and acquire suitable new-tech equipment earlier, to be a leader, not a follower. Finally, policymakers should establish related benchmark indices for what drivers up hospital costs (micro aspect) and to control healthcare expenditures (macro level).

關鍵字(中)

★ 醫院成本
★ 醫療品質
★ 健保制度
★ 成本控制

關鍵字(英)

★ Cost containment
★ Quality of healthcare services
★ Hospital costs
★ National Health Insurance

論文目次

CHAPTER 1 INTRODUCTION 1
1.1. MOTIVATION AND RESEARCH PURPOSE 1
1.2. RESULT PREVIEW 4
1.3. THESIS STRUCTURE 6
CHAPTER 2 BACKGROUND 8
2.1. THE NHI SYSTEM (THE SINGLE-PAYER SYSTEM) IN
DEVELOPED COUNTRIES 8
2.1.1. The National Health Service system in the U.K. 8
2.1.2. The National Health Service system in Canada 10
2.2. The NHI system in Taiwan 12
2.2.1. Before the reform 12
2.2.2. After the reform 13
CHAPTER 3 THEORETICAL FRAMEWORK LITERATURE
REVIEW AND HYPOTHESE 17
3.1 COST AND QUALITY 17
3.1.1 Patients as principals and physicians (hospitals) as agents 17
3.1.2. Owners as principals and the employees (physicians) in
hospitals as agents 19
3.2. COST DRIVERS 20
3.2.1 Aging population 21
3.2.2 Types of diseases 22
3.2.3 New medical technology 23
3.2.4 Length of stay 24
3.2.5 Household income 24
3.2.6 Family size 25
3.2.7 Financial structure 25
3.2.8 Subsidies 26
CHAPTER 4 SAMPLE AND METHOD 27
4.1. METHOD 27
4.2. STUDY MODEL 27
4.3. DATA 31
CHAPTER 5 EMPIRICAL RESULTS 32
5.1. UNIVARIATE ANALYSIS 32
5.1.1 Comparison before and after the NHI 32
5.1.2 Trend analysis – cost and quality 33
5.1.3 Cost and quality before and after the NHI 33
5.2. PANEL DATA REGRESSION ANALYSIS 38
5.2.1 Cost and quality 38
5.2.2 Cost drivers 38
5.3. ROBUSTNESS TESTS 43
5.3.1 Cost drivers 43
CHAPTER 6 DISCUSSION AND CONCLUSION 46
6.1. WHETHER THE NHI HAS ACHIEVED BETTER
COST CONTAINMENT AND QUALITY OF CARE 46
6.2. WHETHER THE INCREASE OF HEALTHCARE
COSTS ARE REASONABLE 47
6.3. WHAT DRIVERS INFLUENCE ESCALATED
COSTS AFTER THE NHI 51
6.4. IMPLICATIONS 54
6.5. CONTRIBUTION 55
6.6. LIMITATION AND FUTURE RESEARCH 55
REFERENCES 56

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指導教授

洪榮華(Jung-Hua, Hung)

審核日期

2007-11-23

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