Chen Li-Chia, Schafheutle Ellen I, Noyce Peter R
School of Pharmacy and Pharmaceutical Sciences, The University of Manchester, 1st Floor, Stopford Building, Oxford Road, Manchester, M13 9PT, UK.
Res Social Adm Pharm. 2009 Sep;5(3):211-24. doi: 10.1016/j.sapharm.2008.08.003. Epub 2009 Jan 31.
Taiwan's National Health Insurance's (NHI) generous coverage and patients' freedom to access different tiers of medical facilities have resulted in accelerating outpatient care utilization and costs. To deter nonessential visits and encourage initial contact in primary care (physician clinics), a differential co-payment was introduced on 15th July 2005. Under this, patients pay more for outpatient consultations at "higher tiers" of medical facilities (local community hospitals, regional hospitals, medical centers), particularly if accessed without referral.
This study explored the impact of this policy on outpatient medical activities and expenditures, different co-payment groups, and tiers of medical facilities.
A segmented time-series analysis on regional weekly outpatient medical claims (January 2004 to July 2006) was conducted. Outcome variables (number of visits, number of outpatients, total cost of outpatient care) and variables for cost structure were stratified by tiers of medical facilities and co-payment groups. Analysis used the auto-regressive integrated moving-average model in STATA 9.0.
The overall number of outpatient visits significantly decreased after policy implementation due to a reduction in the number of patients using outpatient facilities, but total costs of care remained unchanged. The policy had its greatest impact on the number of visits to regional and local community hospitals but had no influence on those to the medical centers. Medical utilization in physician clinics decreased due to an audit of reimbursement declarations. Overall, the policy failed to encourage referrals from primary care to higher tiers because there was no obvious shifting of medical utilization and costs reversely.
Differential co-payment policy decreased total medication utilization but not costs to NHI. The results suggest that the increased level of co-payment charge and the strategy of a single cost-sharing policy are not sufficient to promote referrals within the system. To achieve an effective co-payment policy, further research is needed to explore how patients' out-of-pocket payment affects medical utilization and which forces (not susceptible to co-payment) act in tertiary facilities.
台湾地区的全民健康保险（NHI）覆盖范围广泛，患者可自由选择不同层级的医疗机构，这导致门诊医疗利用率和费用加速增长。为了抑制不必要的就诊，并鼓励在基层医疗（医师诊所）进行首诊，2005年7月15日引入了差别自付额制度。在此制度下，患者在“更高层级”的医疗机构（当地社区医院、区域医院、医学中心）进行门诊咨询时需支付更多费用，尤其是在未经转诊就就诊的情况下。
本研究探讨了该政策对门诊医疗活动和支出、不同自付额组以及医疗机构层级的影响。
对2004年1月至2006年7月的区域每周门诊医疗索赔进行了分段时间序列分析。结果变量（就诊次数、门诊患者人数、门诊护理总费用）和成本结构变量按医疗机构层级和自付额组进行分层。分析使用了STATA 9.0中的自回归积分移动平均模型。
政策实施后，由于使用门诊设施的患者数量减少，门诊就诊总数显著下降，但护理总费用保持不变。该政策对区域和当地社区医院的就诊次数影响最大，但对医学中心的就诊次数没有影响。医师诊所的医疗利用率因报销申报审核而下降。总体而言，该政策未能鼓励从基层医疗转诊至更高层级，因为医疗利用率和费用没有明显的反向转移。
差别自付额政策降低了总体药物利用率，但未降低全民健康保险的费用。结果表明，提高自付额收费水平和单一成本分摊政策策略不足以促进系统内的转诊。为实现有效的自付额政策，需要进一步研究以探讨患者自付费用如何影响医疗利用率，以及三级医疗机构中哪些因素（不易受自付额影响）起作用。
