| Summary: | 碩士 === 國立臺灣大學 === 健康政策與管理研究所 === 105 === Background: Taiwan’s National Health Insurance System was implemented in March 1995. The system has drastically reduced the financial barriers to medical treatment and increased accessibility and choice of health-care providers so that all citizens can get the most basic medical care. This has, of course, resulted in an increase in overall medical expenses. When the SARS epidemic hit Taiwan, the NHI implemented a classification referral system called the Family Physician Trial Plan in order to enhance the quality of care at primary care clinics. The Family Physician Trial Plan has been in place since 2003. Previous literature has pointed out that although the public and most physicians have reported high satisfaction with the medical plan, the number of people receiving care through this plan accounts for less than 10% of the population of Taiwan, while the clinic participation rate is less than 30%. In addition, there is a lack of research regarding how many primary care clinics can take on the functions of family physicians under current conditions in Taiwan.
Objectives: The primary care system is responsible for the management and coordination of patient care. This study will explore how many primary care clinics are able to take on the functions of family physicians. This will be accomplished through exploring patient complexity and the services provided by primary care clinics in Taiwan.
Methods: Data from 2009 to 2013 were obtained from Taiwan’s National Health Insurance Research Database. In this study, we calculated patient complexity using different dimensions, including quantity, variability and diversity. We assessed patient complexity in terms of diagnoses, exams, patient characteristics, medications and other therapies provided by primary care clinics. In addition, we referenced the quality care indicators used in other countries, and then summed up eleven primary care services indicators. Through linear regression and logistic regression, we examined the relationships between division, urbanization and patient complexity and services provided by primary care clinics. We also took into account the relationship between physicians’ specialty, demographic characteristics and primary care services.
Results: The distribution of primary care clinics and physicians between 2009 and 2013 reveals that the proportion of family medicine and internal medicine providers declined every year, while ENT and other specialties increased every year. Primary care clinics also tend to be concentrated in highly urbanized areas. The quantity, variability and diversity of diagnoses and medications per visit of primary care clinics are also increasing every year. Patient complexity is the highest for internal medicine providers, followed by family medicine. The degree of urbanization in the area where the clinic is located is inversely proportional to patient complexity. The results suggest that the eleven primary care services that primary care clinics can provide are: Adult health examination 39.81%, elderly influenza vaccine 25.75%, pap smears 10.17%, breast cancer screening 0.55%, fasting blood lipids 42.08%, glycosylated hemoglobin 36.37%, microalbuminuria 30.46%, eye examination 8.51%, fecal occult blood test 18.73%, colorectal examination 1.68%, and smoking cessation clinic 9.44%. Family medicine and internal medicine provide the highest proportion of primary care services, and in general, the degree of urbanization in the clinics is inversely proportional to the ratio of clinics providing primary care services.
Conclusions: Overall, family medicine and internal medicine clinics in Taiwan are able to take on the functions of primary care providers, but only about 12% of the primary care clinics provide more than half of primary care services. Ideally, primary care services could be spread more evenly between providers. Any effort to improve the referral system should be aimed at strengthening the clinics that aren’t currently able to meet primary care service needs. This is particularly true of primary care clinics in highly urbanized areas.
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