The Critical Policy Issues of Regional Healthcare Expenditure：Price Control and Physician Migration

[[abstract]]本研究主要為探討醫療費用地區總額政策的關鍵議題：價格管控與醫師流動。論文分為兩個醫療政策主題下去分別作探討：一、分科總額是否有助於控制醫療點值？二、基層醫療價格對醫師流動的影響。 第一個主題，以西醫基層總額下的區域總額，針對健保署六大分局(台北區、北區、中區、南區、高屏區、東區分局) 之中區，其引進「科總額」之概念，本研究也以醫療價格或點值作為評估依據，進行長期的模型分析，評估「分科總額」政策的效果，研究結果顯示：相較於其他管制政策對於基層醫療價格增加的效果，「分科總額」政策對於基層醫療價格增加的效果，是令人存疑。 第二個主題，回歸到西醫基層總額政策的原始初衷，分析實施總額預算制度的主要目的之一是在於控制醫療費用的成長，另一是合理分配醫療資源，意旨「錢跟著人走」使用較好「點值」鼓勵醫師到資源較缺乏地區執業，藉以縮小城鄉醫事人力距離，以期增加民眾就醫距離的可近性本研究採取具有虛擬變數的複回歸分析對基層醫療價格與醫師流動之間的影響作探討，其中估計方法皆符合最小平方法(ordinary least square, OLS)的規範，可有效分析月、季週期不同地區的平均點值是否會直接影響醫生流動可能性，故分成月週期與季周期兩大階段研究結果顯示：「西醫基層總額」政策對於價格對醫師流動的影響，是不顯著的。 此兩篇的研究結果，建議政府對於未來醫療體系的改革仍是持續不斷地進行，並確實導入預防醫學的理念，建置更完整的基礎醫療體系(primary healthcare)，對於許多新創的醫療產業可以多給些專案補助及鼓勵私人企業到偏鄉設置醫療資源，讓我們的醫療體系能更完整，亦能解決解健保龐大的財務危機，也讓醫療資源可近性、品質提升，回到設立總額制度最原始的初衷。[[abstract]]The national health insurance system has been implemented in Taiwan since 1995. The government has been inevitably encountering substantial financial challenge as well as other developed countries. Therefore, Taiwan government proposed a macro-level global budget scheme on primary healthcare (PHC) system to control the growth of healthcare expense in 2001, and dividing it into six regional budgets. In order to maintain PHC price more steadily, the Ministry of National Health Insurance Taichung branch further set up 11 ‘departmental’ fictitious budgets under the regional budget scheme in 2007. This study aims to evaluate the effect of departmental global budget of PHC on healthcare prices. Overall, this study had analysed 276 recodes of average prices (point values) in PHC of all regions since first quarter of 2003 to second quarter of 2014. The result reveals that departmental fictitious budget implemented in Taichung region did not increase the PHC prices, if it compared with those in other regions. The conclusion was that smaller regional global budget didn’t necessarily contain healthcare price better comparing than alternative policies. Few studies have been conducted to address issues regarding domestic physician migration due to differentiated healthcare prices among regions, which can be even more politically controversial in countries with regional global budget system under the National Health Insurance or National Health Service schemes. This study aims to explore this issue in Taiwan that is inevitably highly debated under a very unfortunate circumstance in which only limited evidence has been available domestically or internationally. The dependent variable of this study is the net general practitioner migration from 2003 to 2014. The main explanatory variable is the average primary healthcare price or ‘point value’, which comes from the seasonal record of the National Health Insurance Administration. There are total 1,100 observations of average prices. The price of the corresponding month (season) one year before is also included as an explanatory variable. The ordinary least square regressions are used to control possible confounding effects. The study results reveal that the primary healthcare price can significantly and positively affect general practitioner migration, yet only in urban cities. Trying to increase primary healthcare price is not helpful for improving general practitioners to migrate into rural areas, although reducing primary healthcare price of urban cities may make general practitioners migrating out of them. These findings are consistent between the results from monthly and seasonal-based data, indicating a robust fact that was overlooked in previous policy-making process in Taiwan. Some social significances and policy recommendations are discussed in the article as well.[[note]]碩