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    政大機構典藏 > 商學院 > 財務管理學系 > 學位論文 >  Item 140.119/94736
    Please use this identifier to cite or link to this item: https://nccur.lib.nccu.edu.tw/handle/140.119/94736


    Title: 健保部分負擔與支付標準調整政策效果分析
    Authors: 韓幸紋
    Contributors: 連賢明
    韓幸紋
    Keywords: 部分負擔
    支付標準
    一階差分
    差異中差異
    誘發性需求
    Date: 2009
    Issue Date: 2016-05-09 11:45:35 (UTC+8)
    Abstract: 內政部於2002年實施「三歲以下兒童醫療補助計畫」。該計劃期望以減免部分負擔方式來降低就醫門檻,增加幼兒醫療利用。雖然此政策頗受好評,但在健保低部分負擔的前提下,額外減免部分負擔是否增加幼兒醫療利用,有待進一步商榷。由於北市率先於1995年針對3歲以下兒童減免部分負擔,並於1998年將對象擴及4-6歲兒童,這個補助政策的擴充,提供了一個機會瞭解減免部分負擔對幼兒醫療利用的影響。本論文使用1997至2000年健保資料庫中六歲以下兒童的西醫門診資料,分析補助政策擴充至4-6歲兒童時,該年齡組幼兒門診次數是否增加。為了控制估計的可能偏誤,本研究進一步以北縣同年齡兒童為控制組,採用「差異中的差異」(difference in difference)法進行分析。實證結果顯示減免部分負擔平均增加兒童門診次數1.6次,佔全年醫療利用7.8%,所估計的價格彈性為 -0.08。
    至於支付標準調整的政策效果,我們以自然產給付調整為例進行分析。基於台灣居高不下的剖腹產率,健保局於2005年5月,將自然產支付點數加倍至和剖腹產點數一致,期望藉由增加自然產給付來降低剖腹產比率。本研究分析該給付調整是否達到其政策目的。我們利用2003~2007年健保資料庫的生產案件。估計上採用邏輯機率模型(logistic model)和固定效果模型(fixed-effect model)來分析提高自然產支付對降低剖腹產率的效果,並觀察這效果是否在長(前後兩年)、短(前後一年)期有所差異。本文並將剖腹案件依剖腹原因區分為預定剖腹及必要剖腹兩種,分別觀察自然產給付調整對預定剖腹及必要剖腹產比率之影響是否有所不同。結果發現,在控制產婦年紀、前胎剖腹產、醫師工作時間考量等因素下,提高自然產給付後,邏輯機率模型顯示,短期時不論整體或頭胎剖腹產率皆無顯著變化;相同的,在控制醫院及醫師固定效果後,固定效果模型也顯示整體剖腹產率,不論是在長短期,均無顯著下降。這結果隱含醫師所得可能不是決定生產方式的主要因素,健保局需考慮其他方法來降低剖腹產。
    不僅如此,我們更進一步以誘發性需求的角度,分析自然產給付調整政策失效的原因。自然產給付調整後大幅提昇醫師所得,對於醫師接生行為是否造成影響,這個問題和文獻上所謂的「誘發性需求」息息相關。本文主要目的,在於瞭解醫療供給者所得增加後能否減少對剖腹生產的誘發需求,進而降低剖腹產率﹖我們使用1996-2007年健保資料,來檢驗誘發性需求的存在。在進行實證分析中,我們面對三個問題。第一,不同醫師可能具有不同但難以觀察的特性,這些特性可能會影響產婦的就醫院所選擇。忽略這些特性,可能造成內生性的偏誤。第二,供給者所獲得生產健保給付和其剖腹產率高低有相當明顯的關係,以同一時期的供給者所得和其剖腹產比例來分析,亦有引發內生性偏誤的可能性。第三,自然產給付調整是外生變動的價格變化,所產生的效果包含「所得效果」與「替代效果」,而替代效果不應視為誘發性需求。為了解決上述問題,我們採取下列方法。我們使用「一階差分」來控制供給者自身特性。其次,我們以前期所得作為當期所得的替代變數。最後,我們排除價格調整所產生的替代效果。由其估計結果可知,自然產給付調高使得醫師所得增加,卻未明顯使得剖腹產率下降,這個結果與理論推論並不吻合。因此,我們進一步探究其原因。結果發現,醫師在所得損失的情況下, PID效果仍屬有限。
    Reference: 第一章
    中央健保局(2007), 中華民國96年全民健保統計,中央健保局。
    中央健保局(2008), 中華民國96年全民健康保險費率精算報告,中央健保局。
    鄭文輝(2000), “台灣健康保險之現況與展望”,台灣社會保險五十年「社會保險之改革與展望」國際研討會,國立政治大學。
    第二章
    一、中文部分
    中央健康保險局(2006),《全民健康保險統計》,中央健康保險局。
    台北市政府主計處(2006),《台北市統計年報》,台北市政府主計處。
    石曜堂,洪永泰,張新儀,劉仁沛,林惠生,張明正,張鳳琴,熊昭,吳聖良(2003),「國民健康訪問調查」之調查設計、內容、執行方式與樣本人口特性,《台灣衛誌》,22,419-430。
    行政院主計處(1993),《中華民國統計地區標準分類》,行政院主計處。
    行政院主計處(2004),《中華民國臺灣地區家庭收支調查報告》,行政院主計處。
    行政院經建會(1990),《全民健康保險制度規劃技術報告》,行政院經建會。
    李丞華與周穎政(2000),《九二一地震對醫療服務利用率之影響》,行政院衛生署。
    李丞華與周穎政(2002),《全民健保一九九九年部分負擔新制之五大效應評估》,行政院衛生署。
    李卓倫,紀駿輝,賴俊雄(1995),時間、所得與中西醫療價格對中醫門診利用之影響,《中華衛誌》,14(6),470-476。
    林季平與林昭吟(2004),台灣未納保人口特質及未納保原因的初步分析,人口、家庭與國民健康政策回顧與展望研討會。
    胡登淵,魏崇暉,周稚傑(2002),台灣兒童牙科門診需求與部分負擔-1997年-2000年縣市跨年資料之分析,台灣經濟學會2002年年會。
    張鴻仁,楊銘欽,李玉春(1994),《全民健保法入門》,景泰文化。
    許君強,林澤余,沈希哲,張嘉莉,湯澡薰(2006),醫療補貼政策對醫療利用之影響---以台北市兒童醫療補助計畫為例,《北市醫學雜誌》,3(3),75-94。
    陳昕,鄭守夏,蔡淑玲(2007),利用健保部分負擔調漲估算醫院門診價格彈性:一個自然實驗法的觀察分析,未出版。
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    劉文玉(2001),《就醫時間成本對民眾門診醫療利用的影響──以雲嘉地區民眾為例》,國立臺灣大學衛生政策與管理研究所。
    蔡淑鈴,藍忠孚,李丞華,周穎政(2004),失業與醫療利用,《台灣衛誌》,23(5),365-376。
    二、英文部分
    Ashenfelter, O. and Card, D.(1985), “Using the longitudinal structure of earnings to estimate the effect of training programs”, Review of Economics and Statistics, 67(4), 648-60.
    Beck, R.G.(1974),“The effect of copayment on the poor”, Journal of Human Resources, 9, 129-142.
    Card, D. and Krueger, A. B.(1994), “Minimum wages and employment:a case study of the fast-food industry in New Jersey and Pennsylvania”, American Economic Review, 84(4), 772-793.
    Cutler, D. M. and Zeckhauser, R.(2000), “The anatomy of health insurance” , Chapter 11 of Handbook of Health Economics, Edited by A.J. Culyer and J.P. Newhouse, 3rd edition, Elsever, North Holland.
    Eissa, N. and Liebman, J.B.(1996), “Labor supply response to the earned income tax credit”, Quarterly Journal of Economics, 111(2), 605-637.
    Leibowitz A., Manning, W.G., Keeler, E.B., Duan, N., Lohr, K.N., and Newhouse, J.P. (1985), “Effect of cost-sharing on the use of medical services by children: interim results from a randomized controlled trial”, Pediatrics, 75(5), 942-951.
    Lohr, K.N., Brook, R.H., Kamberg, C.J., Goldberg, G.A., Leibowitz, A., Keesey, J., Reboussin, D., and Newhouse, J.P.(1986), “Effect of cost-sharing on use of medically effective and less effective care”, Medical Care , 24(9),331-339.
    Manning, W.G., Newhouse, J.P., Duan, N., Keeler, E.B., Leibowitz, A., and Marquis, M.S.(1987), “Health insurance and the demand for medical care:evidence from randomized experiment”, American Economic Review, 77(3), 251-275.
    Meyer, B.D.(1995), “Natural and quasi-experiment in economics”, Journal of Business and Economic Statistics, 13(2),151-161.
    Newhouse, J.P. and Phelps, C.E.(1974), “Price and income elasticities for medical care services”, in The Economics of Health and Medical Care. Conference on Economics of Health and Medical Care, Tokyo, 1973, New York:Wiley.
    Newhouse, J.P., Manning, W.G., Morris, C.N., Orr, L.L., Duan, N., Keeler, E.B., Leibowitz, A. Marqui, K.H., Marquis, M.S., Phelps, C.E., and Brook,R.H. (1981), “Some interim results from a controlled trial of cost sharing in health insurance”, New England Journal of Medicine, 305(25), 1501-1507.
    O`Grady, K., Manning, W.G., and Newhouse, J.P. (1985), “The impact of cost-sharing on emergency department use”, New England Journal of Medicine, 313(8), 484-490.
    Phelps, C.E. and Newhouse, J.P. (1974), “Coinsurance, the price of time, and the demand for medical services”, Review of Economics and Statistics, 56(3), 334-342.
    Rosett, R.N. and Huang, L.F.(1973), “The effect of health insurance on the demand for medical care”, Journal of Political Economy, 81(2), 281-305.
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    第三章
    一、中文部分
    1. 立法院(2007a),《立法院公報院會紀錄》,台北:立法院。
    2. 立法院(2007b),《立法院公報委員會記錄》,台北:立法院。
    3. 林阿明(2006),《健保調高自然產給付對剖腹產率之影響研究》,國立陽明大學醫務管理研究所碩士論文。
    4. 古智愷(2000),《醫師與醫院管理者對剖腹產管理指標認知、態度及行為之研究》,台灣大學醫療機構管理研究所碩士論文。
    5. 吳嘉苓(2000),產科醫生遇上迷信婦女﹖台灣高剖腹產率論述的性別、知識與權力,《性/別政治與主體形構》。
    6. 楊哲銘(2000),TQIP區域性資料報告,財團法人醫院評鑑暨醫療品質策進會台灣醫療品質指標計劃週年研討會。
    7. 蔡雅慧、黃國哲、宋永魁(2006),實施「前胎剖腹產之陰道生產」論病例計酬對醫師執行剖腹產後自然產之影響,《台灣衛誌》,25,283-292
    8. 駱明慶(2007),台灣總生育率下降的表象與實際,《研究台灣》,3,37-60。
    9. 羅紀琼(2003),良辰吉時與剖腹生產,《台灣衛誌》,22,134-140。
    10. 羅紀琼、劉素芬(2004),院所競爭對醫療處置之影響-以剖腹產為例,《台灣衛誌》,23,71-79。

    二、英文部分
    1. Brown H.(1996),“Physician demand for leisure:implications for cesarean section rates,”Journal of Health Economics, 15, 233-242.
    2. Burns L., Geller S, Wholey D.(1995),“The effect of physician factors on the cesarean section decision,”Medical Care, 33,365-382.
    3. Dubay L, Kaestner R,Waidmann T.(1999),“The impact of malpractice fears on cesarean section rates,”Journal of Health Economics , 18, 491–522.
    4. Gruber J, and Owings M.(1996), “Physician financial incentives and cesarean section delivery,” RAND Journal of Economics, 27, 99-123.
    5. Kessler DP, McClellan B.(1996),“ Do doctors practice defensive medicine? ,”NBER Working Paper . 1996;W5466.
    6. Keeler E, Fok T.(1996),“ Equalizing physician fees had little effect on cesarean rates,”Medical Care Research and Review, 53, 465–471.
    7. Lisa D, Robert K, Timothy W.(1999),“The impact of malpractice fears on cesarean section rates,” Journal of Health Economics , 18, 491-522.
    8. Lo J.C.(2003),“Patients’ attitudes vs. physicians’ determination:implications for cesarean sections,” Social Science and Medicine , 57,91-96.
    9. Lo J.C.(2008),“Financial incentives do always work-an example of cesarean sections in Taiwan,”Health policy, 88,121-129.
    10. McGuire T.(2003),“ Physician agency,”Handbook of Health Economics. Culyer A.J., Newhouse J.P. eds. 3rd ed., Elsever, North Holland.,2003.
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    第四章
    一、中文部分
    中央健保局(2007), 中華民國96年全民健保統計,中央健保局。
    林阿明(2006),健保調高自然產給付對剖腹產率之影響研究,國立陽明大學醫務管理研究所碩士論文。
    吳嘉苓(2000),「產科醫生遇上迷信婦女﹖台灣高剖腹產率論述的性別、知識與權力」,台北:性/別政治與主體形構。
    李玉春(2001),「健保支付標準相對值表之研究-各專科內相對值之建立」,全民健康保險醫療費用支付標準相對值研訂計畫第一次研習會。
    行政院主計處(2008),人力運用調查報告,行政院主計處。
    行政院主計處(1993),《中華民國統計地區標準分類》,行政院主計處。
    林季平與林昭吟(2004),台灣未納保人口特質及未納保原因的初步分析,人口、家庭與國民健康政策回顧與展望研討會。
    許績天、連賢明(2007),「賺得越少, 洗得越多? --- 台灣血液透析治療的誘發性需求探討」,經濟論文叢刊 ,35(4),p415-450
    陳春木(2005),影響初次剖腹產因素之分析及其醫療資源耗用適當性之探討-以2003年健保資料庫為例,高雄醫學大學醫務管理學研究所碩士論文
    施景中(2005),「剖腹產是產婦的失樂園,醫師的原罪? 」,研議訂定適當剖腹產率討論會
    黃俊元,楊銘欽,陳維昭(1997),「產婦特性與採用剖腹產:以台大醫院為例」,中華公共衛生雜誌,16(4),309-318。
    韓幸紋,連賢明(2008a),「提高自然產支付能否降低剖腹產比例?」,台灣經濟學會年會。
    韓幸紋、連賢明(2008b), 「降低部分負擔對幼兒醫療利用的影響:以北市兒童補助計畫為例」,經濟論文叢刊,36(4),589-623
    羅紀琼(2003),「良辰吉時與剖腹生產」,台灣衛誌,22,134-140。
    羅紀琼、劉素芬(2004),「院所競爭對醫療處置之影響-以剖腹產為例」,台灣衛誌,23,71-79。
    二、英文部分
    Blomqvist, A. , “The doctor as double agent: Information asymmetry, health insurance, and medical care,” Journal of Health Economics, 10(4), 411-432.
    Bughin, J.(1991), “An Analysis of the Supplier-Induced Demand in the Hospital Sector : Switching Regime Estimates for Belgium,” Université catholique de Louvain, Institut de Recherches Economiques et Sociales (IRES) Discussion Paper No. 1991006.
    Bost, B.W. (2003), “Cesarean delivery on demand: What will it cost? ,” American Journal of Obstetrics & Gynecology, 188(6),1418-1423.
    Carlsen, F., and J. Grytten (1998), “More Physicians: Improved Availability or Induced Demand?”, Health Economics, 7(6), 495-508.
    Cromwell, J., and J. B. Mitchell (1986), “Physician-induced Demand for Surgery,” Journal of Health Economics, 5(4), 293-313.
    Dranove, D.(1988), “Demand Inducement and the Physician/Patient Relationship," Economic Inquiry, 26, 281-298.
    Dranove, D. and P. Wehner (1994), “Physician-induced Demand for Childbirths,” Journal of Health Economics, 13(1), 61-73.
    Dubay, L., Kaestner, R., Waidmann, T.,(1999)“The Impact of Malpractice Fears on Cesarean Section Rates,” Journal of Health Economics, 18, 491-522.
    Epstein, Andrew and Sean Nicholson, 2005, “The Formation and Evolution of Physician Treatment Styles: An Application to Cesarean Sections,” NBER working paper 11549.
    Evans, R.G.(1974), “Supplier-Induced Demand:Some Empirical Evidence and Implications,” in M. Perlman, ed., The Economics of Health and Medical Care, London:Macmillan
    Fuchs, V. R. (1978), “The Supply of Surgeons and the Demand for Operations,” The Journal of Human Resources, Supplement 1, 35-56.
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    Description: 博士
    國立政治大學
    財政學系
    92255503
    Source URI: http://thesis.lib.nccu.edu.tw/record/#G0922555031
    Data Type: thesis
    Appears in Collections:[財務管理學系] 學位論文

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