The Fairness of Regional Budget Allocation in National Health Insurance and Optimal Risk Adjustment Model

[[abstract]]總額預算支付制度為全民健康保險法明定應實施的制度，該制度透過前瞻性的協定分配預算，達到控制醫療費用上漲與平衡醫療資源分布的目的。目前全民健保總額預算制度已在牙醫(民國87年7月)與中醫(民國89年7月)門診部門分別實施，而西醫部分之總額預算支付制度則由衛生署就西醫基層與醫院兩部分邀請醫事團體代表分別規劃研議，基層診所與醫院部門預計分別於民國90年7月與91年1月實施。本研究主要探討西醫基層總額預算制度下，健保各分局資源合理分配的最佳模式，及其相關風險校正因子的適當性。 本文以全民健保各分局各月西醫門診總醫療費用為分析單位，依人口統計因子、疾病診斷資料、先前利用資料、區域醫療資源及自我評量五大分類，選取影響醫療費用之變數，建立不同的風險校正模型加以比較，以尋求能真實反映各區醫療費用的最佳預算分配模式。具體而言，本研究主要目的為： 1.建構區域群體風險校正模型，探討西醫基層總額預算支付制度下區域資源分配之公平性。 2.探討西醫基層總額預算制度所採取風險校正因子之適當性。 3.探討西醫基層總額預算制度下最佳預算分配模式。 4.探討目前西醫基層總額預算制度各分局預算分配是否合理。[[abstract]]Global budgeting is the statutory payment system of National Health Insurance Act in Taiwan. The payment system is prospective to control medical expenditure to some extent and improve the health resource allocation. In Taiwan, global budget has been applied on dental service and Chinese ambulatory care. Continuously the primary care clinics (HCC) and the Hospitals will be applied soon. This study uses medical care data of Bureau of National Health Insurance (BNHI) in Taiwan from July 1999 to June 2000. We choose several risk-adjusters that are determinants of the growth of medical expenditure to construct different regional risk adjustment model. The risk-adjusters are classify by demographics, diagnose, prior year expenditures, health resource and self-reported health. According to those describe above, we look into optimal risk adjustment model for budget allocation. The purposes of this study are as follows: 1.To construct regional risk adjustment model that improve the fairness of regional medical expenditure allocation for global budgeting in National Health Insurance. 2.To look into optimal risk adjustment model for budget allocation. 3.According to optimal risk adjustment model to estimate the expected medical expenditures of BNHI