The Effect of Outpatient Dialysis Global Budget on Medical and Drug Utilization by End-Stage Renal Disease Patients

台灣罹患末期腎臟病（End-Stage Renal Disease，簡稱ESRD）之盛行率於2002至2008年皆高居全球第一。2009年台灣需長期透析治療的末期腎臟病患就有62,282名，健保花在透析的醫療費用由2002年196.6億元至2009年已高達302.6億元，成長54％。洗腎人口只佔國內人口的0.27％，洗腎費用卻佔了全年健保醫療費用6.33％，透析醫療費用已成為健保財務沈重的負擔。健保局為控制此不斷上升的醫療費用，於2003年實施門診透析總額制度。由之前的研究顯示，實施門診透析總額制度反而明顯增加一般門診（非透析門診）之醫療利用，推測實施前透析患者常用之非透析藥品如降血壓藥、胃腸藥、感冒藥等可能由透析醫療提供者於透析門診免費提供或另外申報健保支付。門診透析總額實施後，透析門診之所有處置皆內含於門診透析總額預算，開立處方藥品會影響門診透析醫療收入，導致透析醫療提供者可能有自利行為，將非透析用藥移轉至一般門診處方，但之前研究只是推斷，並未用數據加以證實此一說法是否成立，因此有必要對此進行實證分析研究，深入探討醫療利用增加的原因。 本研究目的主要為探討門診透析總額制度實施，對末期腎臟病患醫療利用與處方藥品之影響。尤其針對末期腎臟病併高血壓病患門診之醫療利用與降血壓藥品處方之影響，因降血壓藥品不屬透析用藥，本研究擬針對降血壓藥品分析，了解是否有由透析門診移轉至一般門診處方之情形。 研究方法：本研究為一自然實驗(natural experiment)，利用次級資料分析（secondary data analysis），由全民健康保險研究資料庫抽樣歸人檔中擷取2000至2005年六年間的末期腎臟病患除觀察實施前後醫療利用情形，篩選出末期腎臟病患個案樣本數為5,032名及17,161個觀察人年，此外採事前事後對照組比較研究法，針對非透析用藥之降血壓藥作進一步探討，再由抽樣歸人檔中擷取2000至2005年間的末期腎臟病併高血壓病患作實驗組，觀察個案樣本數為1,350名及4,668個觀察人年，並將門診透析總額分實施前（2000年）、實施中期（2001-2002年）、實施後期（2003~2005年）三期，藉由傾向分數(propensity score,PS)配對法選擇具高血壓但非末期腎臟病患的個案為對照組。為降低數次藥價調整對藥品費用之影響，以2003年底健保藥品支付價為參考基準單價，計算各年度藥品基準費用作耗用比較，並加入性別、年齡、Charlson index、SARS、高血壓強制適應症變項，利用差異中之差異法(difference in difference，簡稱DID)與廣義估計方程式（Generalized estimating equation，簡稱GEE），評估門診透析總額制度實施對門診醫療利用與降血壓藥品之影響。 研究結果：本研究結果顯示末期腎臟病病患在實施後一般門診次數皆顯著增加，本研究結果顯示末期腎臟病併高血壓病患在實施後皆顯著增加，在降血壓藥品基準費用每人每年多767.33點，一般門診次數每人每年多3.86次。一般門診有開降血壓藥次數每人每年多4.05次。合併症嚴重度Charlson Index愈高，50歲以上之年齡愈大，愈會增加一般門診與降血壓藥品之利用，SARS期間各項利用皆顯著減少，此外亦觀察到透析門診之降血壓藥品基準費用明顯減少。 門診透析總額制度實施，透析門診屬非透析用藥之降血壓藥品費用降低，但移轉增加至其他總額之一般門診醫療利用與藥費支出反而增加更多，更排擠到其他醫療資源利用。綜合前述，本研究建議一個局部範圍的總額預算制度，需考慮到醫療提供者之自利行為，將可能會導致原本內含之醫療服務移轉至其他總額預算制度。建議局部總額預算制度實施，需預先評估擬定配套措施，避免造成整體醫療利用與藥品費用不降反增之結果；或建議考慮再擴大總額預算服務範圍，同一門診提供透析服務，亦可處方非透析用藥，減少病患看診次數，讓病患就醫更便利，提昇整體醫療資源利用效率。Background: The prevalence rates of end-stage renal patients (ESRD) in Taiwan from 2002 to 2008 were highest in the world. The registered prevalence of ESRD in 2009 was 219,826 cases, health care costs spent on dialysis medical 19.66 billion NTD from 2002 to 2009 had reached 30.26 billion NTD, grew 54%. Dialysis population accounted for only 0.27% of the domestic population, dialysis costs accounted for 6.33% annual health insurance costs, medical costs of dialysis has become a heavy financial burden on health care. National Health Insurance Bureau （NHI）to control the rising medical costs, imposed an outpatient dialysis global budget (ODGB) on outpatient dialysis care. From the previous studies have shown that the implementation of ODGB but significant increase in non-dialysis outpatient medical utilization. Speculated that the implementation of global budget before dialysis patients commonly used drugs such as anti-hypertensive drugs, gastrointestinal drugs, cold medicines may be included by the dialysis provider in the dialysis services provided free of charge or paid for other health care claim. Objective：The main purpose of this study to explore the implementation of ODGB, the impact of end-stage renal disease with hypertensive patients outpatient medical utilization and prescription drugs. Analysis of the implementation of ODGB, resulting in antihypertensive drugs in dialysis clinics to reduce prescription, free of charge, and transferred to other general outpatient prescription. Methods: This study, using a before and after study design with a comparison group, assessed the impact of this policy innovation on outpatient and antihypertensive drugs utilization. Using a difference in difference (DID) strategy and the generalized estimating equation (GEE) approach. In order to construct the intervention group, we selected hypertensive end-stage renal disease patients from the NHI beneficiaries claim data from 2000 to 2005. Observe the number of samples for the 1,350 cases and 4,668 person-years of observation. In order to take into consideration of the phase-in implementation of the caps, we divided the study period into three stages: (1) the pre-ODGB stage (2000), (2) the adaptation stage (from 2001 to 2002), and (3) the ODGB stage (from 2003 to 2005).By propensity score (PS) matching method to choose the hypertensive non-ESRD patients in the control group. To avoid the impact of drug costs for Drug Pricing policy adjustments several times, so the end of 2003 health insurance drug list as the reference price. Calculate the annual cost of health insurance drug list to compare, And add gender, age, Charlson index, SARS, hypertention compelling indications as variables. Findings: The regression-adjusted difference-in-difference estimates revealed that the implementation of ODGB was followed by a significant increase in number of non-dialysis outpatient visit for hypertensive ESRD patients by 3.86 visits per person per year, and the number of antihypertensive drugs prescribed in non-dialysis outpatient visit by 4.05 visits per person per year, and the relative drug cost of antihypertensive drugs was also more than 767.33 per person per year, relative to the change of hypertensive non-ESRD patients during this period. Comorbidity severity (Charlson Index) higher, the greater the age (50 years), the more will increase the general out-patient visits and the use of antihypertensive drugs. SARS period were significantly reduced the utilization, in addition to the dialysis clinic also observed the anti-hypertensive drugs significantly reduced the relative drug cost. Implementation of ODGB, the dialysis clinics of non-dialysis treatment to reduce the cost of antihypertensive drugs, but the total amount transferred to another increase in the general outpatient medical care utilization and expenditures on drugs instead of adding more. Exclusion of other medical resource utilization. The above, this study suggests a local range of global budget system, health care providers must take into account the self-interested behavior may result in containing health care system over to the other global budget, pre-assessment package of measures to avoid increasing the overall medical care utilization and costs of medicines; or consider further expansion of global budget range of services, providing the same outpatient dialysis services, but also non-dialysis prescription drugs, so patients can reduce the frequency to visit the doctor, more convenient medical care to patients and improve the overall health care resource utilization