醫院行為與醫療結果之經濟研究

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李淑芬(Shu-fen Li) 查詢紙本館藏

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產業經濟研究所

論文名稱

醫院行為與醫療結果之經濟研究
(The Economics Study of Hospital Behaviors and Treatment Outcome)

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摘要(中)

本研究的目的在探討醫院行為和醫療結果的關係。醫療結果指標為心臟相關疾病住院病患出院後是否發生30天內死亡與再住院。資料主要來自國家衛生研究院發行之1998年至2008年健保資料庫，並依三個不同議題設定觀察期間。
首先，本研究探討總額預算支付制度的實施對治療密集度與醫療結果的影響。由於總額預算支付制度是一種回溯性的固定預算支付制度，醫療服務供給者的報酬原則上是依浮動點值計算給付。總額預算支付制度的實施讓醫院暴露在收入不確定的風險下，醫院有很強的誘因藉由增加服務量來維持目標收入。為避免其他因素的干擾，我們以2002年第3季西醫總額預算實施前後一年為研究期間，並以設定醫院固定效果的邏輯斯特迴歸模型進行實證分析，結果顯示：總額預算支付制度的實施雖然提高急性心肌梗塞病患的治療密集度，對醫療結果卻沒有顯著影響。
　　第二，為了探討病患的醫療結果是否與其就診時間有關，本研究以1998年至2007年間急性心肌梗塞病患為樣本，分析週末住院的醫療結果是否有別於平日。以醫院固定效果之最小平方迴歸模型所做的實證檢驗結果顯示：週末就診的病患確實容易出現較差的醫療結果，而且主要是發生在非醫學中心的醫院。週末效應的存在很可能與部分醫院在週末的救治人力不足，因而無法施行重要處置有關。
　　最後，本研究探討中大型醫院的成立是否能提昇當地的醫療服務品質。我們以嘉義醫療區域缺血性心臟病病患為研究對象，發現兩家新醫院的成立均有助於改善在地就醫病患的治療結果。而且新醫院成立帶來的品質提昇，很可能與生產力外溢效果有關，也就是面對新醫院成立的威脅時，既存醫院會以提昇自身服務品質來因應。建議衛生主管機關制定相關政策以鼓勵醫院在醫療資源不足區域設立。

摘要(英)

This study aims to investigate the relationship between hospital behaviors and patients’ treatment outcome which is measured by 30-day mortality and readmission rates of heart disease patients. We conduct our research via empirical analyses using the 1998-2008 data extracted from the National Health Insurance database and focus on the following three topics.

First, we examine the effect of the enactment of the global budgets payment system on patients’ treatment intensity and outcome. Since the global budgets payment system is a retrospective payment system with a fixed budget, providers are paid on the basis of a floating point value scheme. Under the global budget, hospitals are threatened by income uncertainty and tend to provide more services to secure their target incomes. The results from xtlogit regression models show that the global budget increases the treatment intensity of AMI patients, but does not have any significant effect on patients’ treatment outcome.

Second, we evaluate whether there is a difference in treatment outcome between patients admitted into hospitals during weekdays and weekends. The empirical results of hospital fixed effects regression models show that the patients admitted during weekends do have a higher rate of adverse outcomes, especially for patients admitted into non-medical-centers. The evidence of weekend effects implies a lower staffing level and the absence of ancillary medical support during weekends for some hospitals.

Third and final, we study how an entry of a large hospital in Chiayi medical area improves the quality of care delivered to the local dwellers. Our empirical results display a significant decrease in mortality and readmission rate of IHD patients in Chiayi medical area after two new hospitals entered the market. Part of the improvement of the care quality might be attributable to the “spillover effect” of medical productivity, i.e., the incumbents respond the threat of new entry by providing better services and quality of care. Our findings might provide some policy implications for policy makers to encourage hospitals entry into the places with inadequate medical resources.

關鍵字(中)

★ 總額預算支付制度
★ 週末效應
★ 新醫院進入市場

關鍵字(英)

★ global budgets system
★ weekend effect
★ new hospitals’ entrance

論文目次

中文摘要 ………………………………………………………………… i
英文摘要 ………………………………………………………………… ii
誌謝 ………………………………………………………………… iii
目錄 ………………………………………………………………… iv
圖目錄 ………………………………………………………………… v
表目錄 ………………………………………………………………… vi
第一章　緒論…………………………………………………………… 1
第二章總額支付制度的實施對治療密集度與醫療結果的影響…… 4
第一節前言…………………………………………………………… 4
第二節台灣保險支付制度演進及醫療費用變化情形……………… 6
第三節文獻回顧……………………………………………………… 10
第四節實證模型設定與實證資料說明……………………………… 14
第五節估計結果……………………………………………………… 20
第六節結論…………………………………………………………… 23
第三章重症病患週末就診的醫療結果……………………………… 27
第一節前言…………………………………………………………… 27
第二節相關的文獻回顧與評論……………………………………… 29
第三節實證模型設定………………………………………………… 31
第四節實證資料說明………………………………………………… 32
第五節實證結果分析………………………………………………… 38
第六節結論、政策意涵與研究限制………………………………… 45
第四章新進醫院對醫療結果的影響………………………………… 51
第一節前言…………………………………………………………… 51
第二節相關的文獻回顧與評論……………………………………… 53
第三節台灣新進醫院概況…………………………………………… 58
第四節實證模型設定與實證資料說明……………………………… 67
第五節實證結果……………………………………………………… 72
第六節結論與研究限制……………………………………………… 84
第五章結論…………………………………………………………… 90

參考文獻

第二章總額支付制度的實施對治療密集度與醫療結果的影響
何瑛、黃偉堯（2005），「牙醫GB制度對牙醫服務量與價格的影響」，台灣衛誌，24：5，394-401。
李冬蜂、吳肖琪（2004），「論病例計酬實施前後冠狀動脈繞道道手術病患死亡情形」，臺灣公共衛生雜誌，23：4，305 -315。
林美珠、沈昱名、文羽苹、史麗珠（2006），「支付制度對醫療資源耗用的探討—以闌尾切除術為例」，醫務管理期刊，7：3，306-322。
陳欽賢、劉彩卿、林建仁、朱子斌、邱文達（2003），「總額支付制度下醫院同儕行為之競合：賽局理論分析」，醫務管理期刊，14：3，68-79。
張育嘉、黎伊帆、汪芳國、鄭守夏（2006），「全民健保實施GB制度之初步影響評估：以牙醫與西醫基層為例」，台灣衛誌，25：2，152-162。
張益誠、廖宏恩（2002），「西醫基層診所實施GB前後之價量變化-以台灣北部地區西醫基層診所為例」，台灣衛誌，21：5，363-372。
葉德豐、王俊文（2002），「西醫基層總額支付制度實施前後費用趨勢之研究-以中部四縣市為例」，醫務管理期刊，3：4，11-29。
潘奇、魏誠佑、祝道松、侯勝茂（2006），「GB實施前後署立醫院營運績效之評估」，醫務管理期刊，7：4，403-417。
簡麗年、吳肖琪（2003），「論病例計酬實施前後全股（髖）關節置換術病患出院後30日內的再住院情形」，臺灣公共衛生雜誌，22：1，69-78。
羅紀琼、詹維玲（2007），「醫院GB對費用單價與服務量的影響初探」，台灣衛誌，26：4，261-269。
Barnum, H., J. Kutzin, and H. Saxenian (1995), “Incentives and provider payment methods,” International Journal of Health Planning and Management, 10, 23-45.
Benstetter, F. and A. Wambachb (2006), “The treadmill effect in a fixed budget system,” Journal of Health Economics, 25, 146–169.
Chang, L., and J. H. Hung (2008), “The effects of the global budget system on cost containment and the quality of care: experience in Taiwan,” Health Services Management Research, 21, 106-116.
Chen, F. J., J. N. Laditka, S. B. Laditka, and S. Xirasagar (2007), “Providers’ responses to global budgeting in Taiwan: what were the initial effects?” Health Services Management Research, 20, 113-120.
Cheng, T. M. (2003), “Taiwan’s new national health insurance program: genesis and experience so far,” Health Affairs, 22(3), 61-76.
Deyo, R. A., D. C. Ch, and M. A. Ciol (1992), “Adapting a clinical comorbidity use with ICD-9-CM administrative index for databases,” Journal of Clinical Epidemiology, 45(6), 613-619.
Dor, A. and D. E. Farley (1996), "Payment source and the cost of hospital care: inferences on quality from a multiproduct cost function," Journal of Health Economics, 15(1), 1-21.
Fan, C. P., K. P. Chen, and K. Kan (1998), "The design of payment systems for physicians under global budget- an experimental study," Journal of Economic Behavior and Organization, 34(2), 295-311.
Hodgkin, D. and T. G. McGuire (1994), “Payment levels and hospital response to prospective payment,” Journal of health economics, 13(1), 1-29.
Hsueh, Y. S., S. Y. Lee, and Y. T. Huang (2004), “Effects of global budgeting on the distribution of dentists and use of dental care in Taiwan,” Health Services Research, 39(6), 2135-2153.
Hurley, J. and R. Card (1996), “Global physician budgets as common-property resources: some implications for physicians and medical associations,” Canadian Medical Association Journal, 154(8), 1161-1168.
Lee, M. C. and A. M. Jones (2004), “How did dentists respond to the introduction of global budgets in Taiwan? An Evaluation Using Individual Panel Data,” International Journal of Health Care Finance and Economics, 4, 307-326.
Milcent, C. (2005), “Hospital ownership, reimbursement systems and mortality rates,” Health Economics, 14(11), 1151-1168.
Mougeot, M. and F. Naegelen (2005), “Hospital price regulation and expenditure cap policy,” Journal of Health Economics, 24, 55-72.
Picone, G. A., F. A. Sloan, S. Y. Chou, and D. H. Taylor, Jr. (2003), “Does higher hospital cost imply higher quality of care?” The Review of Economics and Statistics, 85(1), 51-62.
Romano, P. S., and R. Mutter (2004), “The evolving science of quality measurement for hospitals: Implications for studies of competition and consolidation,” International Journal of Health Care Finance and Economics, 4, 131-157.
Shen, Y. C. (2003), “The effect of financial pressure on the quality of care in hospitals,” Journal of Health Economics, 22, 243-269.
Volpp, K. G. M., S.V. Williams, J. Waldfogel, J. H. Silber, J. S. Schwartz, and M. V. Pauly (2003), “Market reform in New Jersey and the effect on mortality from acute myocardial infarction,” Health Services Research,38(2), 515-33.
Yakoboski, P. J., J. Ratner, and D. J. Cross (1994), “The effectiveness of budget targets and caps in the German ambulatory care sector,” Benefits Quarterly, 10, 31-37.

第三章重症病患週末就診的醫療結果
李麗惠、薛亞聖與楊長興（2006），「週末假日就醫與治療結果之相關探討」，台灣衛誌，2：25，107-114。
Barba, R., J. E., Losa, M. Velasco, C. Guijarro, G. G. Casasola and A. Zapatero (2006), “Mortality among adult patients admitted to the hospital on weekends,” European Journal of Internal Medicine, 17, 322 – 324.
Becker, D. J. (2007), “Do hospitals provide lower quality care on weekends?,” Health Research and Educational Trust, 42(4), 1475-6773.
Bell, C. M. and D. A. Redelmeier (2001), “Mortality among patients admitted to hospitals on weekends as compared with weekdays,” The New England Journal of Medicine, 345(9), 663-668.
Bendavid, E., K. Yevgenia, J. Needleman, L. Gruenberg and J. S. Weissman (2007), “Complication rates on weekends and weekdays in US hospitals,” The American Journal of Medicine, 120, 422-428.
Cram, P., S. L., H. M. Barnett, and G. E. Rosenthal (2004), “Effects of weekend admission and hospital teaching status on in-hospital mortality,” The American Journal of Medicine, 117,151-157.
Crowley, R. W., H. K. Yeoh, G. J. Stukenborg, R. Medel, N. F. Kassell and A. S. Dumont (2009a), “Influence of weekend hospital admission on short-term mortality after intracerebral hemorrhage,” Journal of the American Association: Stroke, 40, 2387-2392.
Crowley, R. W., H. K. Yeoh, G. J. Stukenborg, A. A. Ionescu, N. F. Kassell and A. S. Dumont (2009b), “Influence of weekend versus weekday hospital admission on mortality following subarachnoid hemorrhage,” Journal of Neurosurg, 111, 60–66.
Dorn S. D., N. D. Shah, B. P. Berg, and J. M. Naessens (2010), “Effect of weekend hospital admission on gastrointestinal hemorrhage outcomes,” Digestive Diseases and Sciences, 55(6), 1658-1666.
Evans, W. N. and B. Kim (2006), “Patient outcomes when hospital experience a surge in admissions,” Journal of Health Economics, 25, 365-388.
Foss, N. B. and H. Kehlet (2006), “Short-term mortality in hip fracture patients admitted during weekends and holidays,” British Journal of Anaesthesia 96(4), 450–454.
Gould, J. B., C. Qin, A. R. Marks and G. Chavez (2003), “Neonatal Mortality in Weekend vs Weekday Births , ” JAMA, 289(22), 2958-2962.
Haapaniemi, H., M. Hillbom and S. Juvela (1996), “ Weekend and holiday increase in the onset of ischemic stroke in young women,” Stroke, 27, 1023-1027.
Horwich, T. B., A. F. Hernandez, L. Liang, N. M. Albert, K. A. LaBresh, C. W. Yancy, and G. C. Fonarow (2009), “Weekend hospital admission and discharge for heart failure: Association with quality of care and clinical outcomes,” American Heart Journal, 158,451-458.
Jakovljevic, J. (2004), “Day of the week and ischemic stroke: is it Monday high or Sunday low?,” Journal of the American Association: Stroke, 35,2089-2093.
Jneid, H., G. C. Fonarow, C. P. Cannon, I. F. Palacios, T. Kilic, G. V. Moukarbel, A. O. Maree, K. A. LaBresh, L. Liang, L. K. Newby, G. Fletcher, L. Wexler and E. Peterson (2008), “Impact of time of presentation on the care and outcomes of acute myocardial infarction,” Journal of the American Association Circulation, 117, 2502-2509.
Keatinge, W. R., and G. C. Donaldson(2005), “Changes in mortalities and hospital admissions associated with holidays and respiratory illness: implications for medical services,” Journal of Evaluation in Clinical Practice , 11(3), 275-81.
Kostis, W. J., K. Demissie, S. W. Marcella, Y. H. Shao, A. C. Wilson and A. E. Moreyra (2007), “Weekend versus weekday admission and mortality from myocardial infarction,” The New England Journal of Medicine, 356(11), 1099-1109.
Macfarlane, A. (1978), “Variations in number of births and prenatal mortality by day of week in England and Wales,” British Medical Journal,2, 1670-1673.
Magid, D. J., Y. Wang, J. Herrin, R. L. Ncmara, E. H. Bradley, J. P. Curtis, C. V. Pollack, W. J. French, M. E. Blaney and H. M. Krumholz (2005), “Relationship between time of day, day of week, timeliness of reperfusion, and in-hospital mortality for patients with acute ST-segment elevation myocardial infarction,” JAMA, 294(7), 803-812.
Mastad, O., G. Torsvik and A. Aakvik (2010), “Overworked? On the relationship between workload and health worker performance,” Journal of Health Economics, forthcoming.
Michele, C. and D. E. Hyatt (2006), “Further evidence on the ’’Monday effect’’ in workers’ compensation,” Industrial Labor Relations Review, 59(3), 438-450.
Milcent, C. (2005), “Hospital ownership, reimbursement systems and mortality rates,” Health Economics, 14(11), 1151-1168.
Peberdy, M. A., J. P. Ornato, G. L. Larkin, R. S. Braithwaite, T. M. Kashner, S. M. Carey, P. A. Meaney, L. Cen, V. M. Nadkarni, A. H. Praestgaard and R. A. Berg (2008), “Survival from in-hospital cardiac arrest during nights and weekends,” JAMA, 299(7),785-792.
Person, S. D., J. J. Allison, C. I. Kiefe, M. T. Weaver, O. D. Williams, R. M. Centor and N. W. Weissman (2004), “Nurse Staffing and Mortality for Medicare Patients with Acute Myocardial Infarction,” Medical Care, 42(1), 4–12.
Saposnik, G., A. Baibergenova, N. Bayer, V. Hachinski (2007), “Weekends: A Dangerous Time for Having a Stroke?” Stroke, 38, 1211-1215.
Taira, B. R., H. Meng, M. S. Goodman and A. J. Singer (2009), “Does ‘off-hours’ admission affect burn patient outcome?” Burns, 35(8), 1092–1096.
Tu, J. V., P. C. Austin, R. Walld, L. Roos, J. Agras and K. M. McDonald (2001), “Development and validation of the Ontario acute myocardial infarction mortality prediction rules,” Journal of the American College of Cardiology, 37(4), 992-7.
Wunsch, H., J. Mapstone, T. Brady, R. Hanks, and K. Rowan (2004) “Hospital mortality associated with day and time of admission to intensive care units,” Intensive Care Medicine, 30(5), 895-901.

第四章新進醫院對醫療結果的影響
劉容華與江東亮（2001），「台灣小型醫院新設與歇業之影響」，臺灣公共衛生雜誌，20(1)， 27 -33。
蔡文正、龔佩珍、楊志良、李亞欣與林思甄（2006），「偏遠地區民眾就醫可近性及滿意度調查」，臺灣公共衛生雜誌，25(5)，394- 404。
鄭守夏、劉林義與張毓宏（2001），「新設大型醫院對當地基層診所的影響評估－第一部分：供給與利用的變化」，臺灣公共衛生雜誌，20(1)，52 -60。
謝琇蓮與江東亮（1994），「臺灣地區醫院歇業及新設之決定因素」，中華衛誌，13(6)， 453- 458。
Abraham, J. M., M. Gaynor, and W. B. Vogt (2007), “Entry and Competition in Local Hospital Markets,” Journal of Industrial Economics, 55( 2), 265-288.
Aw, B. Y, X. Chen, and M. J. Roberts (2001), “Firm-level evidence on productivity differentials and turnover in Taiwanese manufacturing,” Journal of Development Economics, 66, 51–86.
Barro, J. R., R.S. Huckman, and D.P. Kessler (2006), “The effects of cardiac specialty hospitals on the cost and quality of medical care,” Journal of Health Economics, 25(4), 702-721.
Buchmueller, T., M. Jacobson, and C. Wold (2006), “How far to the hospital? The effect of hospital closures on access to care,” Journal of Health Economics, 25, 740–761.
Campbell, J. R. (1997), “Entry, Exit, Embodied Technology, and Business Cycles,” NBER Working Papers No. 5955.
Capps, C., D. Dranove, and R. C. Lindrooth (2010), “Hospital closure and economic efficiency,” Journal of Health Economics, 29, 87–109.
Cooper, R., J. Haltiwanger, and L. Power (1999), “Machine Replacement and the Business Cycle: Lumps and Bumps,” The American Economic Review, 89(4), 921 -946.
Dafny, L. S. (2005), “Games Hospitals Play: Entry Deterrence in Hospital Procedure Markets,” Journal of Economics & Management Strategy, 14(3), 513-542.
Lee, M. C. and A. M. Jones (2004), “How did dentists respond to the introduction of global budgets in Taiwan? An Evaluation Using Individual Panel Data,” International Journal of Health Care Finance and Economics, 4, 307–326.
Foster,L., J. C. Haltiwanger, and C. J. Krizan (2001), “Aggregate Productivity Growth. Lessons from Microeconomic Evidence,” NBER Chapters in New Developments in Productivity Analysis, 303-372.
Gaynor, M. (2006), “What Do We Know about Competition and Quality in Health Care Markets? ” unpublished paper, Carnegie Mellon University.
Grossman, J. M. and D. A. Banks (1998), “Unrestricted Entry and Nonprice Competition: The Case of Technological Adoption in Hospitals,” International Journal of the Economics of Business, 5(2), 223-245.
Kessler, D., and M. McClellan (2000), “Is Hospital Competition Socially Wasteful?” The Quarterly Journal of Economics,” NBER Working Papers No. 7266.
Lien, H. M., S. Y. Chou, and J. T. Liu (2010), “The Role of Hospital Competition on Treatment Expenditure and Outcome: Evidence from Stroke and Cardiac Treatment in Taiwan,” Economic Inquiry, 48(3), 668-689.
Lindrooth, R. C.(2007), “The Effect of Entry of Specialty Hospitals and Units on Treatment Intensity: The Case of Cardiac Care,” Working Paper.
Lindrooth, R. C., A. T. Lo Sasso, and G.. J. Bazzoli (2003), “The effect of urban hospital closure on markets,” Journal of Health Economics, 22, 691–712.
Nallamothu, B. K., M. A. M. Rogers, M. E. Chernew, H. M. Krumholz, K. A. Eagle, and J. D. Birkmeyer (2007), “Opening of Specialty Cardiac Hospitals and Use of Coronary Revascularization in Medicare Beneficiaries,” JAMA, 297(9), 962-968.

指導教授

蔡偉德(Wei-der tsai)

審核日期

2012-12-4

推文