總額支付制度實施前後之差異分析─以台灣北部地區西醫基層診所 為例
Initial Impacts of the Global Budget Scheme on the Medical Claims of Primary Clinics－Case of Primary Western Physician Clinics
中文摘要
本研究主要目的在探討西醫基層總額支付制度實施前後對其醫療費用及醫師滿意度之影響，以 作為未來實施醫院總額支付制度參考。本研究利用健保局台北分局「門診醫療費用申報檔」，來 比較89 年及 90 年下半年西醫基層診所醫療費用在總額制度前後的變化情形。並以結構式問卷 調查西醫基層診所醫師對總額支付制度的認知、感受情形及滿意度。此次研究對象為台北縣市、
基隆市、宜蘭縣等台灣北部地區健保特約的基層西醫診所。
研究結果發現，總額制度實施半年：一、西醫基層診所申請件數顯著下降，單位價格顯著增加，
但健保申請金額及合計金額並無顯著差異。二、由迴歸模式顯示，縣市別、城鄉別及權屬別是影 響基層診所件數減少與單位價格增加的因素。三、預防保健部門及慢性病部門等鼓勵部門申請件 數和金額顯著增加，上限制部門申請件數及金額顯著減少；部分佔率較高的科別申請件數及金 額並顯著減少。四、比起總額實施前，診所醫師對總額支付制度的認知瞭解程度明顯增加，對總 額支付制度的感受及滿意度也顯著提昇。而診所醫師的年齡、地區別、權屬別及營業量等基本特 性，與總額制度的滿意程度有關。五、西醫基層診所醫師對總額認知程度愈高，對總額制度的感 受態度愈正面，對總額制度的滿意度也愈高。
根據以上結果，建議衛生主管機關應持續追蹤監測總額預算實施後醫療費用變化情形並分析原 因，並瞭解是否影響民眾就醫便利性和權益。在推行醫院總額支付制度前，應加強宣導讓醫界 充分的瞭解，並建立點值速算機制。建議醫療機構管理者重視就醫人次減少的問題，推動基層 診所與醫院合作模式、同病同酬之支付標準改革及健全審查制度，加強同儕制約力量，提昇醫 療服務的適當性及品質。
英文摘要
The aim of this research is to explore the initial impacts of the Global Budget Scheme on the medical claims and doctors’ satisfaction among Western physician clinics. The conclusion, hopefully, can be a reference as implementing the Global Budget Scheme on hospitals.
Bureau of National Health Insurance Taipei Branch’s File of Outpatient Medical Expense was employed to compare the changes in medical claims among primary Western physician clinics in the same half year before (i.e., 2000/07) and after (i.e., 2001/07) the Global Budget Scheme was inaugurated. Meanwhile, we conducted a structured survey to investigate primary Western physicians’
knowledge, attitude, and satisfaction toward the Global Budget Scheme. The surveyed population includes primary Western physician clinics that are under the contract with National Health Insurance Bureau in Taipei city and county, Keelung
and I-lan County. The major findings are as follows.
1.Six months after launching the Global Budget Scheme, the number of cases claimed from primary Western physician clinics experienced a sheer drop with a significant increase in unit price. However, there are no significant differences in the monetary amount of total medical claims.
2.Our regression model shown that the type of cities, type of townships, and the type of clinics ownerships are significant factors influencing the patterns of decreasing medical claims and increasing unit price index.
3.The number of medical claims categorized in promoting groups such as
preventive health care services and chronic diseases increases dramatically, while that in the other categories with expenditure cap appearing decreases. Parts of medical departments used to occupy high percentage of medical claims also experienced a significant drop in both quantity and accompany amount of money.
4.Compared with the situation before the introduction of the Global Budget Scheme, the primary physicians possess more positive and satisfactory toward the Scheme. The degree of their satisfaction is related to the predisposing characteristics such as ages, practicing areas, ownerships of clinics, and volume of services.
5.Those primary physicians who have better knowledge of the Global Budget Scheme would have more positive attitude as well as are more satisfactory on the Scheme.
Since our findings was confined to the initial impacts of the Global Budget Scheme, it is suggested that the authority continues to monitor the trend to analyze the extent to which people’s access and medical quality would be influenced in the long run. In addition, before implementing the Global Budget Scheme, the authority shall propagate the scheme to the practitioners and establish an automatic unit-price mechanism for well preparation. For health industry part, it is suggested that the hospital administration shall pay more attention on the patient-flow between hospitals and primary clinics, and think the appropriate co-operative model between them. Furthermore, the reforms of Fee Schedule and peer review mechanism also need to be considered for elevating the appropriateness and quality of medical services.
