Tw-DRG政策下的醫院與醫師互動之倫理議題初探

A Preliminary Study of Ethical Issues Between Hospitals and Physicians Under Tw-DRG Policy

林育任(Yu-Jen Lin)

指導教授 ： 許怡欣

共同指導教授 ： 許玫玲(Mei-Ling Sheu)

臺北醫學大學/公共衛生暨營養學院/醫務管理學研究所/碩士(2011年)

摘要

背景：在健保財務快速成長的壓力下，中央健康保險局於2010年1月1日引進了診斷關聯群支付制度，希望能透過此制度達到提升醫療服務效率、改善病人照護品質之目標。此新制度與總額支付制度併行實施，可能使得醫院面臨財務壓力增加，醫院也會將部份財務壓力透過管理介入醫師執業行為轉移至醫師身上。為了瞭解在Tw-DRGs支付制度下是否產生或是加劇某些早已存在的倫理議題，本研究意圖探討醫院管理者和資深醫師之意見，並將之綜合比較，以釐清不同利害關係人之間的矛盾以及在新支付制度下可能遇到之倫理議題。

方法：本研究為一質性研究，探討醫院主管和資深醫師的想法。訪談大綱涵蓋四個引進DRGs制度後的重要議題：(1)醫療資源利用不足；(2)申報取巧；(3)醫療品質之維持及(4)選擇病患。共訪談六位來自不同層級醫院之專家，分別為3位醫院管理階層之主管和3位資深醫師，在深入訪談後利用紮根理論來組織資料。

結果：在組織資料後，研究結果可分為七個構面，分別是Tw-DRGs於台灣實施之背景、受訪者對Tw-DRGs贊成或反對之立場及立論、醫院經營思維與醫師之互動、醫院控制成本對醫療品質之影響、撰寫病歷和申報程序、醫師對病患收治之自主權和醫師對TwDRGs實施後醫病關係變化之感受。

Tw-DRGs於台灣實施之背景：在Tw-DRGs實施之前，台灣的支付制度乃是以論量計酬為主。在健保為醫院主要收益來源的情況下，醫院對於經營管理和財務制度的建置已有一定發展。但是在過度強調管理的過程當中，醫院和醫師如果無法對提供醫療服務的目的有一致共識，將可能造成醫院管理者和醫師之間的價值觀衝突，對於醫療服務品質的提升也可能造成阻礙。
受訪者對實施Tw-DRGs的立場及立論：醫師們贊成新支付制度之實施並認為其可以幫助控制資源利用，但是也擔心這可能會影響到收入。醫院管理者則採取較保守的態度，因為他們對財務壓力的感受更為直接。醫院會透過降低成本(藉由控制人力成本、藥材和醫材成本)以轉移部份財務壓力至醫生身上以減輕所受到的財務壓力。
醫院經營思維與醫師互動：醫院藉由行政介入醫師的執業行為使得醫師配合，在此情況下，醫師執業行為受制於薪水和資源支援之調控。但是在轉移財務壓力的同時，醫院可能過度重視申報程序和降低成本。在此情況下，若是缺乏適當的溝通，可能會加劇醫院管理階層和醫師之間的衝突。
醫院控制成本對醫療品質影響：醫院在論量計酬支付制度時便已採行降低成本等方式以減輕財務壓力。除了透過精簡醫療人力、降低醫、藥耗材成本，醫院也會針對院內的作業流程進行改善，以維持適當的醫療品質。
撰寫病歷和申報程序：在Tw-DRGs實施之後，病歷和申報作業對於醫院的收益更為重要。因此，醫院管理者如果能夠加強疾病分類人員的訓練和醫師對於醫療病歷撰寫的重視程度，對於醫院的收益將有正面的影響。
醫師對病患收治自主權：目前由於Tw-DRGs有不可分案申報(不可以將編碼屬於Tw-DRGs的案件分開申報成多件論量計酬案件)之規則，故醫師在硬體設備或醫療資源不足的時候，會更積極於落實轉診。受訪者均認為產生人球或選擇病患之情形不無可能，必須仰賴主管機關對相關指標之稽查以防止民眾就醫權益受損。
醫師對Tw-DRGs實施後醫病關係變化感受：由於Tw-DRGs目前實施範圍多由原論病例計酬之項目轉變而來，此一新的支付制度目前對醫療領域工作者在執業型態上之改變其實影響並不深，對於民眾的就醫程序也未造成太大的影響。受訪者也認為醫療的高度資訊不對等會讓病患無法察覺醫療品質上的細微變化。

結論與建議：在未來擴大實施Tw-DRGs項目的過程中，財務壓力可能會逐漸增加，而醫院管理和醫師專業自主權之間的衝突可能會加劇。主管機關可建立一平台鼓勵醫院主管和醫師能夠分享臨床醫學進步資訊和心得回饋，藉由資訊更加透明化以及定期修訂Tw-DRGs分類系統和支付標準，也許能更有效率達成Tw-DRGs希望促進台灣醫療品質的目標。

關鍵字

診斷關聯群 ； 申報取巧 ； 選擇病患 ； 紮根理論 ； 倫理議題

並列摘要

Background: Under the pressure of health insurance financial expenditure increasing rapidly, the Bureau of National Health Insurance introduced a prospective system called Diagnostic Related Groups (DRGs) payment system into Taiwan’s healthcare system on Jau, 01, 2010. It intended to promote health care service efficiency and improve quality of health care services.The new payment system cooperated with global budget payment system may cause hospitals facing more financial pressuresome, and the financial pressure may shift from hospitals to physicians through hospital management invoing into physician practice behavior. In order to understand if there are ethical issues happened or reinforced by Tw-DRGs system, we are intended to find out the opinions of hospital managers and senior physicians. And compare those opinions to highlight the conflict between different stakeholders, and what ethical issue they will meet under this new payment scheme, in order to make suggestions when promoting this new policy.

Method: This study applies qualitative reseach, which explores the thinking of experienced hospital managers and senior physicians.The semi-structured interview question list includes four important issues after implementing DRGs system: (1) medical resources underusing, (2) creeping, (3) healthcare quality maintenance, and (4) patient selection. We have interviewed 6 experts, 3 from hospital management level and 3 senior physicians from different levels of hospitals. After in-depth interview, we used grounded theory to organize the data.

Result: After organized the data, the result could be devided into three aspects, which were subjects’ position on implementing Tw-DRGs system, hospitals administration level involving into resources allocation and professional autonomy, physicians’ reception and opinion to the new payment system.

Background of implementing Tw-DRGs in Taiwan: Before implementing Tw-DRGs payment system, Taiwan’s medical payment system was mainly fee-for-services. As National Health Insurance the major income source, hospitals has developed a series of management strategies and finacial system. But during the process, hospital managers and physicians may have values conflict if they can’t reach an agreement to the goal of providing health care services, and it might be a obstacle to promote health care quality.
Subjects’ position on implementing Tw-DRGs system: Physicians approved for the new payment system and think it can help to control the resources use, but also worried about it might affect their income. Hospital managers were more conservative than physicians, because they may feel the financial pressure more directly. Hospitals tried to decrease financial pressure by decreasing cost (which may be achieved by controlling human resoureces and purchasing medicines and medical materials), and shifting some pressure to clinical physicians.
Interactions between hospital management level and physicians: By involing into physicians practice behavior, hospital management level ceased for physicians cooperation. Under the circumstances, physicians’ practice behavior were controlled by their wage and support resources. But during the shifting of financial pressure, hospitals may overvalued the importance of coding procedure and cost down. In that way, the conflict may increase when there were no fully communicate between between hospital management level and clinical physicians.
The effect of cost down to medical quality: Hospitals already implementing ways like cost down to reduce financial pressure under fee-for-services payemnt system. Except through eliminate professional human resources, cut down the cost of medical supplies and medicine, hospitals also focus on improving work procedure to maintain appropirate quality of health care services.
Medical record writing and coding procedure: After implementin Tw-DRGs payment system, medical record and upcoding system play important roles to hospital finance. So if hospital managers reinforce the training of coding specialists and physicians’ writing of medical record, it will have a positive effecct to hospital finance.
Physicians’ autonomy to receive patients: Because physicians can’t devide Tw-DRGs case into different cases, physicians will be more active to transfer patients when they have insufficient equipment or medical resources. And subjects all believe that patients selection and dumping patients are possible, so the authorities need to monitor related indicators to prevent endamage patient’s right.
Physicians feeling for relationships with patients after introducing Tw-DRGs:
The new payment system hasn’t cause major change on physicians’ practice behovior due to the Tw-DRGs items mainly transform from case payemnt items until now. Subjects also believe that the information asymmetric would prevent patients acknowledge the slight difference of health care quality.

Conclusion and suggestion: During the expansion of Tw-DRGs items, the financial pressure may increase, and the conflict between hospital management and physician’s professional autonomy may aggravate. The authority may build a platform for hospital management and physicians to share clinical improvement and feedback. By making the information more transparent and routinely adjusting Tw-DRGs classification system and payment standard, Tw-DRGs original intend of improving medical quality of Taiwan’s health care system may achieved more efficiently.

並列關鍵字

DRGs ； Creeping ； Patient selection ； Ground Theory ； Ethical issue

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