另一種流行趨勢－論成效計酬的趨勢與展望

Just another Trend in Healthcare? A Perspective on Pay for Performance Programs

陳宗泰(Tsung-Tai Chen) ； 鍾國彪(Kuo-Piao Chung) ； 賴美淑(Mei-Shu Lai)

《台灣公共衛生雜誌》 26卷5期 (2007/10) Pp. 353-370

https://doi.org/10.6288/TJPH2007-26-05-02

摘要

歐美各國都面臨品質鴻溝的問題，主要的原因之一是因為過去的支付制度著重在成本／價格的競爭，而不是所謂品質/價值的競賽。在2000年後，歐美各國陸續推出論成效計酬(P4P)的支付制度企圖來解決前述的問題，然而在實務上的成效究竟如何？是否又只是另一股熱潮而已？本篇回顧的目的包含檢視國內外的P4P研究是否提供有效品質改善的證據？國外知名機構等所建議P4P制度設計的原則為何？要考量哪些設計上的兩難？實施後可能有哪些非預期的結果？最後提出國內P4P發展與研究的參考。本篇回顧結論包括，P4P仍缺乏充足且相關的研究、P4P制度最重要在於誘因及測量系統設計，但仍有些兩難尚待考慮，例如誘因量要大或小、要獎勵改善(improvement)或是獎勵成效(performance)，同時一些非預期的結果（例如gaming現象）要先預防。正當英、美如火如荼的試行P4P，並展開評估研究時，我們應截長補短，取法與借鏡歐美各國的經驗，以搭上這股風潮來帶動品質的提升。

關鍵字

健康照護品質 ； 品質鴻溝 ； 論成效計酬 ； 支付制度設計

並列摘要

Many developed countries face problems related to gaps in quality of care. One reason is that past reimbursement schemes focused on a cost/price proposition, not a quality/value proposition. Since 2000, governments in North America, Europe and Australia have launched pay for performance (P4P) initiatives in an attempt to solve gaps in the quality of care. Objectives: This paper addresses several pertinent questions: 1) Does pay for performance really work? 2) Is P4P just another trend in healthcare? 3) Is there empirical evidence to prove the effectiveness of P4P on quality improvement? 4) What principles should be considered in designing a P4P system? 5) What are the unintended consequences after implementation? We conducted a literature review to address the questions posed about pay for performance, and developed a theoretical framework to assist researchers interested in studying P4P issues and programs. Major findings validate several pertinent points. The effectiveness of P4P is still lacking sufficient empirical support, and the development of performance measures and incentives is a major concern in designing a P4P system. Several problems were identified related to sources of money to pay for programs, and whether programs should encourage quality improvement or performance excellence. The prevention of unintended consequences, such as gaming the system to increase payment, is essential. Currently many countries are simultaneously implementing P4P, and conducting evaluations of its effectiveness. Incorporating available knowledge and experiences from a variety of sources may be an effective strategy to enhance the quality of care in Taiwan.

並列關鍵字

healthcare quality ； quality gap ； pay for performance ； design of reimbursement method

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