醫師對論病例計酬醫療品質認知之探討
Exploring Physicians’ Perceptions on Quality of Care Under the Case Payment System
中文摘要
自全民健康保險制度實施後，醫療費用成長幅度驚人，為了抑制論量計酬造成的醫療費用支出 高漲，八十四年七月起中央健康保險局陸續推出論病例計酬，並且計畫九十四年全面實施住院 論病例計酬。素來醫師以其專業素養及知識來判斷及提供醫療照護，但面對論病例計酬支付制 度下，目前仍少有關探討服務於各層級醫院醫師，對整體論病例計酬醫療品質的觀點，以及對 論病例計酬醫療品質指標監控系統的認知與評估的相關報告。本研究目的在探討醫師對整體論 病例計酬醫療品質的看法及由醫師的觀點，評估論病例計酬之下，所需之醫療品質指標與論病 例計酬對醫療品質所造成的影響，以供衛生主管機關未來在訂定全面住院論病例計酬支付制度 政策時，於設計醫療品質監控系統時納入參考。並且對於可能出現造成醫療品質負面影響的結 果防範於未然。本研究以大台北地區的地區教學醫院層級以上的外科、骨科、婦產科及泌尿科醫 師為研究對象，採取分層隨機抽樣，進行結構性問卷調查，總共發出332 份問卷，其中有效問 卷的回收率達60.8%。
本研究結果發現高達63.9%的醫師認為目前論病例計酬項目疾病之整體醫療品質有下降的現象，
只有19.8%的醫師認為醫療品質有提昇。對於目前中央健康保險局論病例計酬支付制度的品質 監控系統，認為不好的醫師佔55.5%，認為好的只有 6.4%。醫師認為重要之論病例計酬品質 監控指標依序為併發症或合併症之產生、設定高額除外案例、出院健康狀態、住院死亡率、病患滿 意度、院內感染率、推趕病人或拒收病人、風險校正後死亡率及病歷記載完整性。對於目前論病例 計酬支付制度實施下，認為對醫療品質造成影響的認同度最高為會造成推趕病人或拒收病人，
其次為會造成疾病編碼取巧行為及會提高醫療糾紛發生比率。而認為病患滿意度會提昇者最低。
醫師的年齡、年資及有無參與規劃或執行醫療品質管理計畫或活動與參加醫療品質的教育訓練 課程的經驗，會影響其對整體論病例計酬支付制度醫療品質的認知。醫師所屬醫院特質（醫院 權屬別、醫院層級）、醫師個人特質（性別、年齡、診療模式）、醫師專業背景（教育背景、年資、
科別、職別、行政職）及醫師有無參與醫療品質有關之經驗（參與規劃或執行醫療品質管理計畫 或活動、參加醫療品質的教育訓練課程的經驗）均會影響其對醫療品質指標重要性的認知。
英文摘要
The Bureau of National Health Insurance (BNHI) initiated a case payment system based on diagnosis-related groups (DRGs) in 1995 to contain the profound increment of medical expenditures induced by fee-for-service reimbursement. Furthermore, BNHI plans to implement the prospective case payment system to all inpatient services in 2004. Physicians provide the medical care by their professional experience and judgment of the quality of care. However, there were few reports about the physicians’ perspectives on the quality of care under the case payment system. The aims of this study are exploring (1) the physician’s perceptions on the overall quality
of care after implementation of case payment system, (2) the physician’s perceptions on the mandatory necessity of quality indicators under the case payment system, and (3) the physician’s perceptions on the influence of quality of care under the case payment system.
The research subjects were stratified sampling among 332 surgeons, orthopedists, obstetricians & gynecologists and urologists from teaching hospitals in metropolitan Taipei. A structured questionnaire was used to collect data and the response rate was 60.8%.
Among the samples, 63.9% perceived that the overall health care quality became
“much worse” or “worse” under the case payment system. On the contrary, only 19.8% perceived “much better” or “better” overall health care quality. With respect to quality monitoring by BNHI after implementation of case payment system, 55.5%
perceived “much worse” or “worse” quality of care. In contrast, 6.4% perceived
“better” and even none perceived “much better” quality of care.
This study revealed the most mandatory quality indicators that had to be monitored under the case payment system are occurrence of complications or comorbidities, outlier cases, health status upon discharge, in-hospital mortality rate, patient satisfaction survey, nosocomial infection rate, refusal of admission or patient dumping, risk-adjusted mortality rate, and complete documentation. The worsen influences perceived by physicians are refusal of admission or patient dumping, coding creep and medico-legal litigation; however, most do not agree that patient satisfaction will be improved after implementation of case payment system.
This study revealed that the physicians’ perceptions on quality of care under the case payment system are influenced by the physicians’ hospital characteristics (hospital ownership, hospital status), personal characteristics (age, gender, clinical decision making models), professional background (educational background, professional experience, specialty, visiting staff/resident, co-administrator), and the experience of involving quality management plans and/or attending the training course of quality management activities.
