長期以來，藥價差對醫師「處方行為」的影響，一直是研究者關切的焦點問題。一般認為，在經濟誘因影響下，醫療提供者為極大化經濟利益，會增加處方藥品量；而此行為不但造成醫療費用上升與醫療資源浪費，更影響百姓的用藥權益與安全、及健康品質的保障。然而，「藥價差」屬於交易雙方之間秘密，不易被觀察出，且處方藥品項目又極為眾多，因此想全面性的以「藥價差」來實證醫師處方藥品行為，難度頗高，故過去少有研究從事此類分析。
回顧先進OECD國家之藥品醫療市場制度，除美國為自由交易經濟市場外，其他國家之藥品醫療市場皆是由政府高度介入，而由於各國政府對其藥品與醫療的不同政策與制度，也反應出不同的結果與效應。於本研究，以台灣全民健保制度作為研究個案，以分析台灣全民健保制度的特點，作為本實證研究假設推論的理論基礎。同時，本研究也以台灣全民健保醫療資料庫之門診就醫資料，作為實證樣本，並不限定就醫科別、藥品類別、或藥品製造商，藉以達到本實證研究之內外部效度。
本研究是以2008年與2010年台灣全民健保醫療資料庫門診就醫資料之「門診處方治療明細檔 (CD檔)」與「門診處方費用明細檔(OO檔)」為樣本，經串檔，以取得每一處方之治療與藥品明細。爾後，再與台灣健保署2009年(第六次藥價調整)與2011年(第七次藥價調整)之藥品價格調整明細表，進行比對，而得以推算出醫師每一處方所開立之「藥品量」與「藥價差」，並再繼予推算、「處方藥價差」與「處方總藥價」等資訊。
本研究是以類別二元化之羅吉斯迴歸式進行實證研究分析，結果顯示﹕整體而言，西醫醫療機構處方決策行為(無論論量計酬或論件計酬)且有涉及經濟誘因之傾向，但其涉及經濟誘因之傾向，會因為醫療機構權屬別的不同而有差異。於醫院(只能論量計酬)方面，當處方箋具有藥價差、藥品量多時，醫師處方決策行為傾向不願釋出處方箋。於基層診所(可論量計酬或論件計酬)方面，醫師處方決策行為傾向依其自身條件，選擇適宜與有利的方式申請處方藥品費。

For quite long time, researchers around the world has been investigating the effects of drug price difference on drug and physician’s prescription behavior. The general view is that medical providers, under economic incentives to maximize economic benefits, will increase the prescribe prescription drugs. Such behavior results in rise of medical expenses and the waste of medical resources, further more it affects people’s right and safety of medicine usage, compromise the people’s quality of health. As “drug price difference” is a secret between the buyer and seller that is difficult to observe, and there is a vast amount of prescription drugs. With such difficulties, not much research with full statistical analysis is done using “drug price difference” as key proof for a doctor’s drug prescription behavior.
Looking at pharmaceutical and medical market of modern OECD countries, except for the free-trading market of U.S.A., the government of all other countries are highly involved to form plan-based markets. In each case, the different policies on drugs and medical system set by various governments also reflect their effects, advantages, and disadvantages. In this study, we use Taiwan National Health Insurance (TNHI) as a research case, and analyze its characteristics as a basis for theoretical and hypothesis inference of the research. At the same time, this study used TNHI medical outpatient database as empirical sample data and without restricting medical department or drug type, or drug manufacturers. This is to conduct a more comprehensive and random test to validate the internal and external validity of this research.
This study uses prescription treatment detail (CD file) and prescription cost detail (OO file) in 2008 and 2010 TNHI medical outpatient database. After combining the two files, we shall get each prescription’s the detailed information of the detailed information about “drug item”, “drug quantity”, ”drug price (old price before adjustment)”. And after comparing the combined CD-OO data with the sixth (2009) and the seventh (2011) of Taiwan’s Health Insurance Agency’s bi-annual report of the drug price adjustment summary list (new price after adjustment), we can calculate “drug price difference” and extrapolate “prescription drug price difference”, “prescription total drug price”.
This study uses logistic regression to analyze the physician prescription behavior. The empirical results are the physician prescription behaviors are involved in economic ncentives, whether the payment way of the fee for service and the diagnose with a fixed
payment in Taiwan’s National Health Insurance. And the effect degree of economic incentive shall be different by the different medical ownerships (public, corporation, private). From hospitals in the payment way of the fee for service only, the physician prescription behaviors are not willing to release the prescription when the prescription has the drug price difference and much of drugs. From clinics in either the diagnose with a fixed payment or the payment way of the fee for service, the physician prescription behaviors are forward to choose the suitable and beneficial ways based on their conditions to apply the out-patient drug fees.

目 次
論文審定書……………………………………………………………………………………………………….…..i
誌 謝…………………………………………………………………………………………………………………..ii
摘 要…………………………………………………………………………………………………………………..iii
ABSTRACT……………………………………………………………………………………………………………..iv
第一章 緒論…………………………………………………………………………………………………………. 1
1.1 研究背景…………………………………………………………………………………………… 1
1.2 研究動機…………………………………………………………………………………………… 3
1.3 研究目的…………………………………………………………………………………………… 6
1.4 研究流程…………………………………………………………………………………………… 7
1.5 研究架構........................................................................................................9
第二章 文獻回顧…………………………………………………………………………………………………. 11
2.1藥費、價格與數量關係……………………………………………………………..………11
2.2醫療提供者處方的經濟行為………………………………………….......................12
2.3給付制度對醫療行為的影響……………………………………………………………… 15
第三章 國際藥品政策與給付制度簡介…………………………………………………………………17
3.1澳洲藥品收載及訂價方式簡介……………………………………………………….....18
3.2英國藥品支付制度簡介……………………………………………………………………….20
3.3美國醫療保險及藥價制度簡介……………………………………………………………22
3.4瑞典藥價結構簡介……………………………………………………………………………….24
3.5加拿大藥品支付制度簡介……………………………………………………………………25
3.6日本藥品支出制度簡介……………………………………………………………………….27
3.7韓國藥價制度簡介……………………………………………………………………………….29
3.8荷蘭藥價制度簡介……………………………………………………………………………….31
3.9法國藥價結構及定價方式簡介……………………………………………………………31
3.10德國藥品定價方式簡介…………………………………………………………………….34
3.11瑞士藥價制度簡介……………………………………………………………………………..36
第四章 台灣全民健保制度特徵…………………………………………………………………………….41
4.1醫藥分業雙軌制度……………………………………………………………………………….41
4.2藥品交易代理人制度……………………………………………………………………………42
4.3以處方箋作為藥品費給付(憑證)制度…………………………………………………43
4.4台灣健保藥品訂價制度……………………………………………………………………….43
4.5健保藥品給付制度的不同……………………………………………………………………45
第五章 假設推論…………………………………………………………………………………………………….47
5.1 藥價調整的基本概念………………………………………………………………………….48
5.2 健保藥價差的辨...……………………………………………………………………………..48
5.3 本研究實證藥價差之定…………………………………………………………………….49
5.4 以論量計酬之假設推…………………………………………………………………………49
5.5 以論件計酬之假設推論……..……………………………………………………………….50
5.6 實證模型變數因果關係示意圖……..……..……………………………………………51
第六章 實證方法………………………………………………………………………………………….……….53
6.1藥價差推算概念………………………………………………………………………………….53
6.2資料……………………………………………………………………………………………………..54
6.3樣本……………………………………………………………………………………………………..54
6.4變數……………………………………………………………………………………………………..55
6.4.1論量計酬之變數……………………………………………………………………………….55
6.4.2論件計酬之變數……………………………………………………………………………….57
6.5實證模型……………………………………………………………………………………………..58
6.5.1論量計酬實證模型……………………………………………………………………………58
6.5.2論件計酬實證模型…………………………………………………............................ 59
第七章 實證結果………………………………………………….......................................................60
7.1 描述性統計……………………………...................................................................60
7.1.1 論量計酬方面…………………….....................................................................60
7.1.2 論件計酬方面…………………….....................................................................63
7.2 實證結果與分析…………….…….....................................................................65
7.2.1論量計酬方面…………….…….......................................................................65
7.2.2論件計酬方面…………….…….......................................................................74
7.2.3本研究實證結果總結語............................................................................82
第八章 結論與討論……………………………………………………………………………………………...84

參考文獻
中文文獻………………………………………………………………………………………………………………..88
英文文獻………………………………………………………………………………………………………………..90

圖目次
圖1、研究流程圖………………………………………………………………………………………………......8
圖2、研究架構圖………………………………………………………………………………………………….10
圖3、論量計酬實證模型變數因果關係示意圖……………………………………………………51
圖4、論件計酬實證模型變數因果關係示意圖……………………………………………………52

表目次
表1、2000年台灣與OECD主要國家藥品支出水準的比較……………………………….20
表2、2001年至2012年台灣西醫基層診所與醫院門診之處方釋出率………………46
表3、論量計酬實證變數描述性統計………………….......................................................61
表4、論量計酬實證樣本描述性統計………………….......................................................61
表5、不同權屬別醫療機構(含醫院與診所)實證樣本之描述性統..........................62
表6、論量計酬醫療機構權屬別(醫院與診所)之描述性統計分析..........................63
表7、論件計酬西醫基層診所實證樣本之描述性統計..............................................64
表8、論件計酬西醫基層診所實證變數之描述性統計..............................................64
表9、論量計酬-應變數處方行為與藥品相關變數之關係分析................................67
表10、論量計酬-應變數處方行為與藥品、醫療機構相關變數之關係分析.........68
表11、論量計酬-應變數處方行為與藥品、不同權屬別醫療機構之關係分析....73
表12、論件計酬-應變數是否使用簡表與藥品相關變數之關係分析.....................76
表13、論件計酬-應變數是否使用簡表與藥品、醫療機構變數之關係分析.........77
表14、論件計酬-應變數是否使用簡表與藥品、不同醫療機構變數之關係分
析...........................................................................................................................82

附錄......................................................................................................................................97
附表1 2000年至2007年全球OECD國家藥品消費占國民醫療保健支出之比率
..............................................................................................................................................97

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