開業醫師對聯合執業之參與意願與模式之質性研究

目的：本研究的目的旨在探討1．基層開業醫師不願參加聯合執業的原因；2．提昇基層開業醫師參加聯合執業意願的措施及3．基層開業醫師期待的聯合執業模式。方法：採用實地訪談及焦點團體座談方法來進行資料的收集，於2001年11月至2001年12月期間，分別於北（兩次）、中（一次）、南（一次）部舉辦四次的焦點團體座談會，每次人數約12~5人，參與座談的成員為中華民國基層醫療協會在當地的會員。結果：在基層開業醫師不順參加聯合執業的原因方面有1．病人的來源不足：2．健保局對基層醫療健檢項目的限制；3．合理門診量的計算方式複雜；4．有關現行稅率的規定會限制醫師參與聯合執業的意願；5．大醫院門診的競爭；6．健保門診手術的給付項目太少：7．基本的常態性開支比一般診所大及8．目前台灣實施聯合執業的經驗太少。在可提昇基層開業醫師參加聯合執業意願的措施方面有1．提高健保對聯合執業的給付標準；2．簡化支援醫師申報手續；3．現行稅法明確化；4．增加健保門診治療的給付項目；5．放寬聯合執業檢驗項目跨表限制；6．對有意成立聯合執業的醫師給予補助或是低利貸款；7．對聯合執業相關法案的修改。基層開業醫師期待的聯合執業模式為1．在所有權方面：醫師擁有；2．醫師數目方面：由兩位至三位醫師組成；3．在管理方式方面：由醫師自行負責管理；4．在採購儀器之支出方面：由使用儀器的醫師共同分攤；5．在收入分配方面：採國定薪資加績效方式；6．在支援醫師方面：大多數醫師認為醫師認為聯合執業內之支援醫師應該來自診所；7．在儀器設備方面：聯合執業場所內最好有藥局、檢驗、超音波、心電圖及X光等醫療輔助設備。結論：欲提昇基層醫師參與聯合執業的意願，實有待衛生署及健保局修訂相關法規條文及支付制度並增設多重誘因來配合。

關鍵字

基層醫療；聯合執業

並列摘要

Objective: The purposes of this study are to explore: (1) the factors of preventing primary care physicians from joining group practice (2) the factors of encouraging primary care physicians to join group practice and (3) the applicable model of group practice for primary care physicians. Methods: This study used on-site interviews and focus groups to collected data. In total, four focus groups including two in Taipei, one in Taichung, and one in Tainan were held during the period of October to November 2001. The subjects participating focus groups were the members of the Chinese Primary Care Association. Results: The factors prevent the primary care physicians from joining the group practices are as follows: (1) the inadequate sources of patients (2) the regulations of the National Health Insurance; (3) the calculation of the reasonable number of outpatient services 4) the current tax regulations; (5) the competition from hospital ambulatory center; (6) the inadequate number of outpatient surgery 7) the high fixed costs; and (8) the inadequate experience with the group practice in Taiwan. The factors that encourage the primary care physicians to join the group practice are: (1) to increase the reimbursed rate for the primary care; (2) to simplify the procedures of the supportive physicians (3) to clarify the current tax regulations; (4) to increase the number of outpatient surgery paid by the NHI; (5) to loosen the limited number of labs; (6) to provide the loan for physicians who are willing join the group practice; and (7) to amend the regulations about the group practice. The applicable model for the group practice includes: (1) ownership: hospital-owned group practice model is preferred; (2) number of physician: 2 to 3 physicians in a group practice is favored; (3) management: managed by physicians is desired; (4) expenses for medical equipment: shared by the physicians who used the machines; (5) revenue: most physicians have a preference of fixed income/production based; and (6) supportive physicians: physicians considered the sources of supportive physicians should come from other clinics; (7) supplemental equipments: physicians preferred d pharmacy, lab, ultrasound, EKO, and x-ray. Conclusions: The willingness of the primary care physicians can be elevated by amending the regulations and reimbursed policies in relation to the group practice.