Impacts of Self-Precertification Review on Medical Care Quality and Expenses—Example of Total Knee Arthroplasty
本研究之目的在於探討中央健康保險局(以下簡稱健保局)實施自主事前審查試辦作業後，對全 膝關節置換術的醫療品質及醫療費用之影響。本研究利用民國91 年至 93 年台北分局的全膝關 節置換術健保申報資料，並採用類實驗設計(Quasi-experimental Design)的研究方法進行探 討。實驗組於上述研究期間，隸屬於健保局台北分局轄區醫院中，參與自主事前審查試辦作業 的11 家醫院，共有施行全膝關節置換術之病患 1,220 人，而對照組則為未參與此試辦作業之 醫院，共有施行全膝關節置換術之病患5,411 人。另一方面，本研究並以民國 92 年 1 月 1 日 政策介入為切點，以使用差異中之差異法(Difference in Difference, DID)，以分析自主事前 審查作業的實施對住院醫療費用的影響。最後，使用複迴歸分析來檢定影響全膝關節置換術相 關因素。
內再住院之機率較實施前為低。本研究發現，疾病嚴重度、醫院評鑑等級、醫院年手術量、醫師手 術量及專科年資等是病患住院醫療費用的預測因素。依據本研究的研究發現，茲對健保局提出 下列建議：1.健保局仍應持續監測試辦醫院之全膝關節置換術病患的醫療品質；2.試辦醫院的 病患住院費用比未參與試辦醫院較高之原因應詳加探討，以做為未來醫療費用監控之參考；3.
The purpose of the study was to investigate the impacts of self-precertification review of total knee arthroplasty(TKA) on medical care quality and expenses. The quasi-experimental design was used. There are 1220 TKA cases from 11 hospitals participating the self-precertification program were enrolled as the experimental group, and 5,411 TKA cases from other hospitals which did not participate the self-precertification program were enrolled as the control group adopted from claim database of Taipei branch of National Health Bureau(NHIB) in year 2002 to 2003. Difference in Difference(DID) was carried out for analyzing the impact on medical expenses of self-precertification program. Meanwhile, regression analyses were used to investigate the effect of independent variables of TKA.
We found that the average expenses of patients receiving TKA in the participating
hospitals were significantly lowered after participating the self-precertification program. With DID analyses, we also found that the expenses both in the experimental group and the control group were decreased after the initiation of the self-precertification program. However, we found that the expenses in the experimental group were significantly higher than the control group after the program’s initiation. In addition to the expenses, the experimental group had a lower rate of re-admission within 30 days after the initiation of the program. We further demonstrated that there were no significant differences in mortality, surgical complications, and re-admission within 90 days between both groups. The severity of illness, the level of hospital accreditation, the surgical volume of the hospital, the surgical volume, and the practice seniority of the surgeon were noted to be important explanatory factors for the medical expenses of TKA.
Base on the above findings, we proposed several suggestions for the NHIB. First, though there is no significant difference in the quality of TKA before and after the initiation of the self-precertification program for TKA, continuous monitoring of the surgical quality in the experimental group should be encouraged. Second, further study is needed to determine the reasons why the TKA expenses of the
experimental group are higher than those of the control group, so as to monitor the expenses of the procedure in the future. Third, the indicators of the quality of post operation in the experimental group should be established under the
supervision of NHIB. Finally, the national artificial knee registry system should be established to increase the safety for the patients and successful operation results