The Effect of Out-of-Pocket Expenditure on the Seeking Behavior in a Hierarchical Medical Care System: The Multinomial Logit Model

[[abstract]]台灣醫療體系運作，在全民健保制度下分為四個層級，醫療申報費用依層級分級給付，並以門診分級部分負擔試圖落實分級醫療制度，並抑制醫療費用。本研究以離散選擇模型，估計民眾就醫行為的決策因素，探討自付醫療費用對民眾就醫層級選擇的影響。 資料來源為衛生署「100年民眾自付醫療費用問卷調查」，以多項式logit模式分別以門診需求與住院需求建構計量模型。研究結果發現消費能力高的會選醫學中心，所得支配能力較低傾向選擇基層診所尋求醫療照護；居住地都會區的民眾選擇偏好高層級醫療院所，非都會區則偏好低層級醫院，城鄉差異與不同高低層級醫療院所的偏好有一致的趨勢；健康條件不佳而相對需求較多醫療資源的民眾，在低層級的醫療院所就醫的機率較高。疾病越複雜，選擇高層級醫院的機率越高；越高層級的醫療院所就醫選擇，民眾花費越高的時間成本。 以控制疾病複雜度的模型估計醫療服務需求者的特質，負擔醫療費用以外的消費能力越高，相對偏好較高層級醫療院所的醫療服務，所得階層較高或自付醫療費用較少的醫療需求者，比所得階層較低或醫療費用負擔高的民眾，選擇大醫院的機率較高，隱含自付醫療費用連動影響不同付費能力階層選擇的不同層級醫療院所的就醫決策。醫療需求者居住地的城鄉差距是醫療可近性的重要指標，醫療價格會分配不同社經地位民眾的就醫選擇，進而衍生社會福利減損與健康照護公平性的政策意涵，本研究依此研究結果，檢視全民健保制度下的資源配置效率，可提供政策參考的實證依據。[[abstract]]Operate of hierarchical care system under the National Health Insurance in Taiwan. The system contains medical centers, regional hospitals, district hospitals and primary care clinics. It was an attempt on implement a tiered medical system and suppression of medical expenditure. In this study, discrete choice models with an estimated seeking behavior of the people in decision-making factors to explore the impact out-of-pocket on the medical level of the people chose. Data source from the survey of out-of-pocket by Department of Health. Multinomial logit model constructed econometric model for out-patient and hospitalization demand need. The results showed that high spending power would choose medical center, and the low-income strata to choose primary care clinics to seek medical care. The gap between urban and rural areas of residence consistent trend to use a different high and low-level hospitals, poor health conditions relative to demand more medical resources of the public, the higher the probability of medical treatment in low-level hospitals. The people with more complex disease that chose higher probability of high-level hospitals; Patients spend higher time cost when chose the higher-level hospitals for medical treatment. Estimated demand for medical services by the characteristics of the model in the control of disease complexity. Higher consumption capacity, other than the burden of medical expenses relative preferences for the medical services of the high-level medical institutions, compare with low-income status or people with high medical expenses, more the high-income status or pays less medical expenses medical needs chose high level hospitals；It was implied out-of-pocket expenditure that linked capacity to pay for decision-making of hospital level. It was an important indicator for the medical service access to the health care resource between urban and rural areas. The medical price will be allocated different socio-economic status of people for health care service. There was derived fairness impairment of social welfare and health care policy implications. The findings of this study so view the efficiency of resource allocation under the National Health Insurance system, an empirical basis for policy reference.[[note]]碩