Evaluation of Inpatient Medical Services and Professional Reviews at the Bureau of National Health Insurance

In order to contain the medical resources abuse and the rising expenses, the Bureau of National Health Insurance (BNHI) has implemented medical audit and case payment systems. And, hopefully it can maintain the quality consistency of health care services. This study utilized the sampled data audited by the northern office of the BNHI from Aug. 1997 to Feb. 1998. It explored the consistency of medical professional audit and also looked into the service contents of inpatient care after the implementation of case payment. The main findings of the auditing consistency are: Among the disapproved cases, those from the higher levels of hospitals had shorter average length of stay and less average disapproved expenditures. The audit results from non-specific specialists were different from the departmental specialists. The variation of auditing physicians had interacted with the various disease severity; and it increased the variation of auditing results. In terms of service contents for the diseases reimbursed by the case payment: The average lengths of stay for appendectomy and hernia and the claimed expenditures were less than they were after the implementation of case payment. The same decreases were found for their standard variations. After the implementation of case payment, hospitals had provided more consistent inpatient service items for the same kind of diseases. There existed differences between the actual service contents and the minimal service items suggested by the medical associations which required further examinations. Based on the above results, we suggested that those claims within the normal expenditures might not need to be audited. And, the professional audit might focus on the items of radiology, laboratory and exams, pharmacy, and operations. Besides, the BNHI should provide professional training periodically for auditing physicians, in order to increase the consistency of treatment patterns.

Project ID:PG9408-0413
External Project ID:DOH87-NH-006