前瞻性付費制度(Prospective Payment System)之醫療管理模式研究

Integration and Application of Medical Management Model under Prospective Payment System

莊逸洲(Yi-Chou Chuang) ； 陳理(Lee Chen)

《中華公共衛生雜誌》 13卷6期 (1994/12) Pp. 485-499

https://doi.org/10.6288/CJPH1994-13-06-04

摘要

自1960年代晚期起，美國醫療費用支出開始加速成長，造成醫療財政上極大的壓力，其全國醫療費用總支出佔國民生產毛額(GNP)比例到1992年已接近14%，而世界各國只要實施健康保險或社會保險之國家，均同感醫療費用的上漲所造成的衝擊，各專家學者紛紛投入各項研究，期望抒緩財政危機，1983年美國國會通過社會安全法修正案之決議DRGs/PPS(Prospective Payment/Pricing System Based on DRGs)，將醫療費用支付制度由論件計酬制改為前瞻性付費制度，之後世界各國亦相繼採用，此種以約束費用給付之新方法建立了醫院及醫師、護士等醫療人員唇齒相依之合作觀念，並對改進病患之醫療建立共識。我國之醫療費用持續成長已是不爭的事實，依全民健康保險規劃，有關住院費用將採用診斷關係群(DRGs)作為醫院服務項目的支付基準，但由許欠缺健全的成本會計制度及完整之病歷分類管理，擬先實施單一疾病支付制度(Case Payment)，依此而官，我國與世界許多國家一樣，面臨一個新的醫療給什方式，為求因應醫療與管理人員必需縝密合作、互補所短並建立一套管理制度，以控制醫療成本及維護醫療品質。
為了控制醫療成本及維護醫療品質許多專家提出許多管理之方法與對策如：醫療處置的標準化及住院前、住院中及回溯審查，醫師檔案制度等作業是其中重要一環，醫療資源管理亦扮演不可或缺之角色，甚至組織架構的重整亦為其中一角，這許多方法與對策均有專家研究証實有效，但至今並未有人可將各種有效之管理對茉重整以今揮更高效益，本模式將各專家學者研究今表實際有效之管理方法，如臨床醫療參考基準定義醫療過程及醫療處置標準，以適當的使用醫療服務，另如住院中審查及回溯審查等對醫療作業之成本及品質作持續之改善，其它如設施運用審查、醫師檔案應用、醫師教育訓練等方法經過深入研究、探討，去蕪存精、整合串連起來，為使管理模式之訂定完全被醫療人員接受以確切執行達成管理目的。模式設計時需考量之重點相當多，如充份尊重醫療專業，給予應有之自主性，不以行政手段干預醫療，將行政之角色定位淤幕療作業上，而高效率管理項採行Z理論的策略，Z理論為科學式管理及人際關係管理的綜合體，科學式的管理最重要的發展是目標管理，人際關係管理方面則為參與式管理，將二項管理加以結合，則可獲得一種『參與式目標管理』，作為PPS的管理理論基礎，管理實務作業則以簡單之作業方式進行重點或異常管理，增加作業成功率。另異常之提出並非作為懲處之用，而係作為醫師共同檢討之題目，檢討結果為修正基準之依據。此模式以緊密結合各專業人員各司其職貫穿會串，以收事半功倍之效。為改善現行低效率之人工或紙上作業，並由電腦資訊管理專家就醫療資料特性多次研擬，完成龐大之住院病患管理作業藉由電腦協助之處理模式，並以不增加電腦線上作業之負荷，但可達成各項預先設定之目的為首要重點，此管理模式是將控制醫療成本及維護醫療品質有效方法之串連，是一套可提高效率、有具體效益而簡單可行之管理模式。

關鍵字

P.P.S Prospective Payment System ； Managerial Model ； Practice Parameter ； Concurrent Review ； Retrospective Review

並列摘要

From the late 60's, there has been a huge increase in medical expenses in the US. The ratio of total medical expenses to GNP was nearly 14% in 1992. As a result, heavy burden was put on the country's economy. Similar financial impact can be felt by any country implementing health insurance. Hence, a lot of research was carried out, aiming to lessen such financial crises. When the Prospective Payment/Pricing System (PPS) based on DRGs bill was passed in the US in 1983, the method of payment changed from fee for service to PPS, and was then adopted by many other countries. This new payment method has encouraged the cooperative concept among hospitals, doctors and nurses. It is now evident that medical costs in Taiwan continue to rise sharply. According to the national health insurance scheme, DRGs will be used as the basis for in-patients payments. However, as we are lacking a satisfactory cost accounting system and the management of medical record classification is still not flawless, it is now planned that the method of Case Payment will be used when the system starts. To face the new payment system, medical specialists and hospital management personnel must cooperate closely to control medical cost, and at the same time maintain high quality of health care services. Policies and models proposed to achieve these objectives include standardization of concurrent and retrospective review. Important cores are the estalishment of profiles of medical doctors, the management of medical resources and structural reorganization. Research have shown that such policies are effective. Nevertheless, no one to date has combined all of these to formulate a single comprehensive model. This model includes the procedures involved in defining practice parameters and standards. It also examines the continue improvement in cost and quality control by concurrent and retrospective review. In addition, utilization review, application of doctors profile and continued education for medical practitioners are all parts of the model. With careful editing and compilation, this model is designed to be applicable and effective. Special attention is paid to ensure that the medical professionals are fully respected. The role of the management is to provide administrative support but not to interfere with any practices. Operational procedures for abnormal management, the purpose of which is for revision and discussion but not punishment, must be simple. Medical data analysis is an importnat domain in our model formulation. Information and system analysis experts are consulted to consider how to accomplish all the predetermined goals without increasing computer CPU workload substantially. As the model combines of all effective cost and quality control methods, we anticipate that the use of this simple effective managerial model will increase efficiency and productivity of a hospital.

並列關鍵字

DRGs Diagnosis Related Groups ； Case payment ； Managerial Model ； Practice Parameter ； Concurrent Review ； Retrospective Review