模擬Tw-DRGs實施對醫院資源耗用之影響-以Cardiac Cath、PTCA及CABG為例

Abstract

Background: Health care expenditure of National Health Insurance (NHI) in Taiwan has grown significantly since its implementation in 1995. The Bureau of NHI (BNHI) adapted experience from foreign countries and phase in Tw-DRGs in 2010 which used a more efficient incentive payment for controlling the growth of medical costs, improve efficiency and quality of care, According to the statistics of BNHI, circulatory system disease consumed 2.4% services which occupied the highest volume and expenditure of NHI, also it ranked top 2 of Taiwan mortality rate. The purposes of this study are to explore the factors which affected hospital resources utilization of Cardiac catheter, percutaneous transluminal coronary angioplasty and coronary artery bypass graft by Tw-DRGs simulation. Methods: We used the 2007-2009 National Health Research Institute inpatient data, which were connected the basic file (HOSB) with expenses file (DD) of hospital, 12 DRGs of circulatory system disease which comprised 101,346 patients extracted by BNHI software (version3.3). The hospital length of stay (LOS), cost and difference between Tw-DRG fix payment and actual expenditure were tested by affecting factors such as hospital characteristics, patient demographic data and disease severity. Then we presented the descriptive and inferential statistics by SPSS16.0 software. Result: The results showed the majority of hospital days and costs of Cardiac Cath., PTCA and CABG were decreasing when it closed to the date of Tw-DRGs implementation. We believe that hospital has taken certain measures to cope with the new payment systems. In the multiple regression analysis, the variation of the cost of cardiac catheterization was explained 61% (R2=0.61) by independent variables of severity of illness, hospital ownership, hospital area and LOS (p<0.001). The variation of PTCA cost was explained 51% (R2=0.51) by independent variables of gender, hospital ownership, hospital area, hospitalization year and length of stay are (p<0.001). The variation of CABG cost was explained 24% (R2=0.24) by independent variables of severity of illness, level of hospital and LOS (p<0.001). The variation of LOS and Tw-DRG fix payment and actual expenditure cost difference had similar results in multiple regression analysis. We also found independent variables of Cardiac Cath. and PTCA had higher explanatory power than CABG. Furthermore, the hierarchical regression analysis showed the LOS was the most important factor affecting the hospital costs and Tw-DRG fix payment and actual expenditure cost differences, the coefficients of determination (R2) for the Cardiac Cath and PTCA were all above 0.35. Conclusion: The results showed that characteristics of hospital and patient, disease severity were significant factors affected hospital. We suggests that the BNHI should consider above significant factors when revise the payment unit. Besides, workflow of hospitalization and the ability of physician chart documentation should be strengthen, and coder should be more proactive in identifying effective complications and commobidities to optimize the payment.