「論質計酬制」是現在世界各國正逐漸推行的健保給付制度, 其主要精神為依據醫療品質來給付醫事服務提供者, 藉由適當的財務誘因, 鼓勵醫生給予病人更妥善的照護。本研究選取台灣目前的五個論質計酬試辦計畫中的結核病計畫進行制度評量。我們利用疾管局提供的94年結核病資料庫和健保局提供的試辦計畫名單, 並採用Abadie and Imbens (2006) 的計量方法: 最近鄰域配對估計式(nearest neighbor matching estimator) 來估計不同醫院層級和權屬加入試辦計畫後, 完治率是否顯著提高。我們衡量完治率的指標包括:「所有結核病通報病例完治的比例」以及「痰培養陽性病患完治的比例」。不管用哪一種指標, 診所皆是完治率顯著提高最多的層級。而控制在層級底下公私立醫院比較的話, 私立醫院效果比公立醫院大(區域醫院這一層級例外)。總體而言, 實施此一制度可使結核病完治率顯著提高10%以上。

none

1 前言 1
2 結核病的背景與健保制度 3
2.1 結核病簡介 3
2.2 健保有關結核病的專案 4
2.3 論質計酬支付制度 5
3 簡介平均實驗效果 (Average Treatment Effect) 8
3.1 Rubin’s Model 8
3.2 樣本選擇偏誤 (Selection Biases) 10
3.3 認定與估計 12
3.3.1 迴歸 13
3.3.2 配對 (Matching) 15
3.3.3 比較最小平方與配對估計法 18
3.3.4 Propensity Score 的作用 19
4 配對估計法 21
5 實證分析 24
5.1 資料處理 24
5.2 變數 25
5.3 模型 32
5.4 實證結果 33
5.5 成本效益分析 40
6 結論 41

Abadie, A., D. Drukker, J. L. Herr, and G. W. Imbens (2001). Implementing Matching
Estimators for Average Treatment Effects in Stata, The Stata Journal, 1, 1–18.

Abadie, A. and G. W. Imbens (2006). Large Sample Properties of Matching Estimators
For Average Treatment Effects, Econometrica, 74, 235–267.

Bodenheimer, T., H. May, R. A. Berenson, and J. Coughlan (2005) Can Money Buy
Quality ? Physician Response To Pay For Performance, Center for Studying Health
System Change, 102, 1–4.

Brewer, T. F. ,S. J. Heymann, and M. Ettling (1998). An effectiveness and cost analysis
of presumptive treatment for Mycobacterium tuberculosis, American Journal of
Infection Control, 26, 232–238.

Culter, D. M. (1995). The Incidence of Adverse Medical Outcomes Under Prospective
Payment, Econometrica, 63, 29–50.

Dehejia, R. (2005). Practical Propensity Score Matching: a reply to Smith and Todd,
Journal of Econometrics , 125, 355–364.

Dehejia, R. H. and S. Wahba (1999). Causal Effects in Nonexperimental Studies: Reevaluating
the Evaluation of Training Programs, Journal of the American Statistical
Association, 94, 1053–1062.

Hahn, J. (1998). On the Role of the Propensity Score in Efficient Semiparametric Estimation
of Average Treatment Effect, Econometrica, 66, 315–331.

Heckman, James J. (1976). Common structure of statistical medels of truncation, sample
selection, and limited dependent variables and a simple estimator for such models,
Annals of Economic and Social Measurement, 5, 475–492.

Heckman, J. J., H. Ichimura, P. E. Todd (1997). Matching as an Econometric Evaluation
Estimator: Evidence from Evaluating a Job Training Programme, Econometrica,64, 605–654.

Hirano, K., G. W. Imbens, and G. Ridder (2003). Efficient Estimation of Average Treatment
Effects Using the Estimated Propensity Score, Econometrica, 71, 1161–1189.

Holland, P. D. (1986). Statistics and Causal Inference, Journal of the American Statistical
Association, 81, 945–960.

Imbens, G. W. (2004). Nonparametric Estimation of Average Treatment Effects under
Exogeneity: A Review, The Review of Economics and Statistics, 86, 4–29.

Josephine, G. (1994). Controlling Resurgent Tuberculosis: Public Health Agencies, Public
Policy, and Law, Journal of Health Politic, Policy, and Law, 19, 107-147.

Lee, M. J. (2005). Micro-Econometrics For Policy, Program, And Treatment Effects.

Manski, C. F. (2005). Partial Identification of Probability Distributions.

Millenson, M. L. (2004) Pay for performance:the best worst choice, Qual. Saf. Health
Care, 13, 323–324.

Pagan, A. and A. Ullah (2005). Nonparametric Econometrics.

Pearl, J. (2001). Causality.

Peter, C. and N. York (2004) Quality Incentives: The Case Of U.K. General Practitioners,
Health Affairs, 23, 112–118.

Rosenbaum, P. R. (2002). Observational Studies.

Rosenbaum, P. R. ,and D. B. Rubin (1983). The Central Role of the Propensity Score
in Observational Studies for Causal Effects, Biometrika, 70, 41–55.

Rosenthal, M. B., R. Fernandopulle, H. S. R. Song, and B. Landon (2004) Pay For
Quality:Providers’ Incentives For Quality Improvement, Health Affairs, 23, 127–
141.

Rubin, D. B. (1974). Estimating Causal Effects of Treatments in Randomized and Non-randomized Studies, Journal of Educational Psychology, 66, 688–701

Sally, T., M. Au, and J. B. Christianson (2006) Health Plan Pay-for-Performance Strategies,
The American Journal of Managed Care, 12, 537–542.

Shaikh, A. M., M. Simonsen, E. J. Vytlacil, N. Yildiz (2005). On the Identification of
Misspecified Propensity Score, Working Paper.

Sloan, F (2003). Not-For-Profit Ownership and Hospital Behavior, Chapter 21 of Handbook
of Health Economics.

Smith, J. A., and P. E. Todd (2001). Reconciling Conflicting Evidence on the Performance
of Propensity Score Matching Methods, The American Economic Review,
91, 112–118.

蔡文正(2002). 全民健康保險肺結核病患醫療改善方案試辦計畫之評估, 行政院衛生署九十一年度
委託研究計畫。

蔡文正(2003). 結核病患失落之因素分析研究, 行政院衛生署疾病管制局九十二年度委託研究計畫。

蔡文正(2005). 健保結核病專案對於結核病防治工作的影響評估, 行政院衛生署疾病管制局九十四
年度委託研究計畫。

胡曉雲, 蔡文正, 龔佩珍(2005). 肺結核病患未完成治療原因探討, 台灣衛誌, 24, 348–359.

王怡婷, 莊乃蓉, 黃曼媛, 許清曉(1999). 台灣地區結核病防治績效不彰的原因探討及建議, 院內感
染控制, 9, 263–270.

行政院衛生署疾病管制局(2006). 結核病診治指引

中央健康保險局(2002). 全民健康保險肺結核醫療給付改善方案試辦計畫支付標準

中央健康保險局(2004). 全民健康保險結核病醫療給付改善方案試辦計畫