研究成果摘要

計畫編號:DOH91-NH-1020
計畫名稱:全民健康保險肺結核病患醫療改善方案試辦計畫之評估
執行機構:中國醫藥大學
研究人員:蔡文正
執行期間:91年11月1日至92年10月31日


  衛生署每年公佈之國人主要死亡原因中,「結核病」一直名列其中,也是法定傳染性疾病中死亡人數最多的疾病。健保局為了提高肺結核完成治療比例,並且改善現行論量計酬支付方式轉為強調疾病管理之追蹤照護並提昇醫療品質,落實購買健康的新理念,自2001年11月起,陸續推動包括:子宮頸癌、乳癌、肺結核、糖尿病和氣喘等疾病的醫療給付改善方案試辦計畫,期與醫界共同努力,提供民眾以醫療品質與結果為導向的整體性醫療照顧服務。

  本研究針對肺結核論質計酬試辦計畫進行成效評估,評估是否加入肺結核論質計酬之患者其接受治療之完治率與治療完成期間長短是否有差異,並且探討影響肺結核患者完治與否之相關因素,以及比較論質計酬制度實施後,是否加入之肺結核論質計酬之患者於完成治療期間,其醫療費用支出情形。並分析罹患肺結核之民眾對其治療過程與結果之滿意程度,與探討醫師對肺結核論質計酬作業流程與給付內容之滿意度。

  本研究可分為兩大部分,第一部份針對試辦計畫所包含之新增肺結核患者與相關醫師進行醫療品質與滿意度相關問卷調查。以描述性統計描述加入試辦計畫與未加入試辦計畫,完治與未完治之樣本患者特性,以及其醫療支出、患者之整體滿意度、完成治療之時間、完治率之情形,並且以t-test、卡方檢定及變異數分析等統計方法進行檢定。利用複迴歸分析(multiple regression analysis)找出影響患者對於治療之滿意度之相關因素。此外,並利用羅吉斯迴歸分析(logistic regression analysis)探討影響肺結核患者是否完成肺結核疾病治療之相關因素,由於研究的時間限制,本研究對於是否完治以治療後九個月之狀態為依據。第二部份採用健保資料庫進行醫療費用,完治率和治療時間分析比較,針對論質計酬試辦區域-健保局中區分局所管轄之區域(包含臺中縣、臺中市、彰化縣市及南投縣),2001年11月開始至2002年12月為止,納入試辦肺結核論質計酬制度之所有收案對象、未加入試辦計畫肺結核患者,以及試辦計畫開始前一年(2001年)的新增肺結核患者,並且已完成治療者為對象。

   結果發現,試辦計畫確實縮短肺結核完治患者的治療期間,若以九個月的治療期間為標準,依據本研究健保資料分析結果呈現出試辦計畫內完治率為83.81%,非試辦計畫則為57.60%;不同層級醫院之完治率以醫學中心的完治率(九個月)顯著較低。在比較所有完成治療的平均天數方面,以試辦計畫內完治的平均治療期間最短,平均完治天數為224日。然而,民眾對於治療的滿意度,在試辦計畫組中的滿意度比較低。治療過程中仍然是以服藥時間長、服藥產生的副作用等因素為困擾肺結核民眾之主要問題。此外,關於醫師對於此試辦計畫的看法部分,多數醫師都認為試辦計畫對於完治率的提高有幫助,但是對於健保之申報流程、申報系統、費用結構表示滿意的人數比較少。仍然有25.34%的受訪醫師對於試辦計畫的內容不瞭解,有加強宣導的必要。

   因此本研究建議健保局應(1)繼續推廣肺結核論質計酬制度;(2)增加對醫院及醫師有關論質計酬制度之說明;(3)參考醫師之意見改善申報或治療過程相關規定;(4)避免“雙軌制”支付制度之現象;(5)對肺結核病患就醫之部分負擔一致化;(6)健保局與疾病管制局建立單一管理機制。對於醫療院所建議其應(1)建立合適之作業申報與管理流程;(2)推動治療準則;(3)鼓勵醫師將患者納入論質計酬制度內。對於醫師建議其應(1)加強肺結核患者之追蹤與聯繫;(2)增進與患者之溝通並提高服務品質,以提高其滿意度;(3)加強對於患者之心理建設以提高患者配合治療之意願。

關鍵詞:肺結核、論質計酬、完治率、失落率、就醫滿意度


ABSTRACT

  In Taiwan, not only the tuberculosis is one of leading causes of death recently, but also the annual number of death of tuberculosis is the highest among all infectious diseases. In order to increase cure rate of tuberculosis, improve treatment quality, and give more health care responsibilities to the health care providers, the Bureau of National Health Insurance (BNHI), since November of 2001, has implemented the “quality payment” demonstration programs which included the treatments for tuberculosis, breast cancer, cervical cancer, asthma, and diabetes. The BNHI hopes to furnish the patients with comprehensive health care services that emphasize health care outcomes and qualities.

  The purpose of this study was to evaluate the tuberculosis demonstration programs of quality payment. This study evaluated the differences of the cure rates, the treatment times, and treatment expenditures for tuberculosis patients between the demonstration program and current fee-for-services payment programs. In addition, the factors, which influenced the successful treatment to tuberculosis, were analyzed. The satisfaction of medical services for tuberculosis patients was examined. Finally, the physicians’ attitudes and opinions to the demonstration program were surveyed.

   This study consists of two parts. In the first part, the study used the structured questionnaire to interview tuberculosis patients, and we also used questionnaire to survey the relative physicians’ opinions for the demonstration program. The descriptive statistics were used to compare patients’ characteristics, treatment expenditure, satisfaction of medical services, treatment times, and cure rate between the demonstration programs and non-demonstration program. Multiple regression analysis was conducted to explore the relative factors that influenced the patients’ satisfaction with treatment process and outcomes, and logistic regression analysis was applied to examine the factors that significantly affected tuberculosis patients if they could be cured within 9-month treatment. In the second part, based on NHI medical claim data this study conducted statistical analyses for comparing the spending, cure rate, and treatment time for tuberculosis patients between demonstration program and non-demonstration program. The study period was from January 2001 to December 2002. The samples comprised all tuberculosis patients who were new cases and were cured in demonstration program or non-demonstration program in 2002, and those who were new tuberculosis patients and were also cured in 2001 before the implementation of demonstration program.

   The results showed that tuberculosis patients in the demonstration program indeed had shorter treatment times. According to the consequences of analyzing NHI medical claim data, there was 83.81% cure rate in terms of 9-month treatment for those participating in the demonstration program, and 57.60% cure rate for non-participants. Furthermore, the medical-center hospitals had the lowest 9-month cure rate as compared to other-level health care organizations. The average treatment time for cured patients under the demonstration program was 224 days, which was shorter than that of non-participants. The patients, however, in the demonstration program felt less satisfaction with treatment services. The main problems for many tuberculosis patients were a long period of medication and the side effects of medicines. For physicians, most physicians believed the demonstration program is helpful to increase cure rate, but they showed less satisfaction with claim procedures, claim software systems, and payment structures. There were still 25.34% of surveyed physicians who didn’t understand the demonstration program.

   According to results, we propose the following recommendations: for the Bureau of NHI: (1) entirely implement the quality payment program for tuberculosis treatment; (2) enhance the interpretation of the quality payment program to health care providers; (3) improve the NHI claim process and relative regulations according to the opinions of physicians; (4) avoid to simultaneously implement quality payments and fee-for-service payments for tuberculosis treatment; (5) have the same NHI co-payment for tuberculosis treatment at any health care organizations; (6) establish an integrated management system between BNHI and the Center for Disease Control for managing tuberculosis patients. For health care organizations: (1) build an appropriate NHI claim procedure for tuberculosis quality payment; (2) develop the standard clinical guidelines for tuberculosis treatment; (3) encourage physicians to place their tuberculosis patients to participate in the quality payment program. For the relative physicians: (1) enhance to follow up the patients’ treatment status and compliance behaviors; (2) promote the communication with patients to increase patients’ satisfaction and health care quality; (3) increase the patients’ compliance of medicine by intensifying patients’ psychology for tuberculosis treatment.

Keywords: Tuberculosis, Quality payment, Cure rate, Defaulted rate, Satisfaction.