Moral Hazard or Provider’S Induced Demand?

[[abstract]]本研究擬利用兩階段自組織映射網路圖( Self-Organizing Map, SOM)以及調整後臨 床群組病例組合系統(Adjusted Clinical Group Case-Mix System, ACG 系統)，探討影響被 保險人醫療資源使用的變動因素，以及部分負擔、總額預算等健保制度對於醫療費用的 控制效果。首先由第一階段SOM 的群聚，將醫療利用同質性較高的被保險人分類，分 析被保險人的醫療利用程度特徵，以形成不同的醫療成本聚類。第二階段SOM 以網路 圖座標連結每一被保險人在不同的健保制度實施期間內的醫療利用變動，形成一組成本 軌跡，作為第二階段SOM 之輸入向量，以分析動態期間醫療利用變動之特徵。其次， 本研究擬以ACG 預測被保險人的罹病軌跡(morbidity trajectory)，以與SOM 的醫療成本 軌跡加以對照，從而探討健保制度變動對於醫療費用的動態控制成效。 由被保險人風險成本軌跡以及 ACG 的罹病風險軌跡之變動模式，本研究擬探討被 保險人在何種情況下較容易產生道德風險。在兩種軌跡具備一致趨勢時，此時被保險人 的醫療成本軌跡反映其罹病風險程度，本研究擬以此做為衡量健保部分負擔以及總額預 算制度實施成效的控制組，以評估健保制度的費用控制效果。再者，本研究擬進一步分 析被保險人醫療成本的高低，對於健保制度的費用控制成效是否產生差異。例如總額支 付制度對於重大傷病患者與非重大傷病患者的費用控制效果是否相同。而在控制醫療費 用之外，健保制度是否可能對被保險人的罹病風險造成不良影響。例如實施部分負擔新 制之後，被保險人是否延遲就醫，而造成罹病風險提高。最後，本研究擬探討在被保險 人罹病風險不變的情況下，醫療費用的增加是否來自於醫療機構的誘發性醫療需求。[[abstract]]The purpose of this research is to investigate the effects of copayment and global budget payment system on medical utilizations in Taiwan’s National Health Insurance (NHI). This study develops a novel two-level Self-Organizing Map (SOM) for characterizing the static feature of medical cost and the dynamic changing pattern of the cost trajectory in an attempt to discover the reasons for the variation in medical expenses and to evaluate the cost sharing effects for the demand and supply sides. By mapping and cross-referencing the International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) diagnosis codes to the Adjusted Clinical Groups (ACGs) codes, this research intends to decompose medical costs into exogenous (beyond the control of patients and physicians) and endogenous categories. Several types of medical costs of the insured and cost trajectories patterns will be identified through the first and second level SOMs respectively. The characteristics of the medical cost clusters, the changing pattern of the cost trajectory within the sample population, as well as the medical cost control effects of the co-payment system and the global budget payment system are discussed in this research. The question as to whether an individual’s medical cost increase/decrease is caused by actual changes in health status or by the effects of the health-payment system reforms will be answered. Throughout this research, the underlying limitations and conditions of the cost containment effects of the demand- and supply side incentive instruments will be analyzed.[[note]]NSC101-2410-H327-01