醫院總額預算自主管理制度之效益分析：以臺北市立聯合醫院為例

Effect on a Self-management Payment System on Global Budget in Taipei City Hospital

紀櫻珍(Ying-Chen Chi) ； 張偉斌(Weu-Pin Chang) ； 劉德明(Der-Ming Liou) ； 許朝程(Chao-Cheng Hsu) ； 吳振龍(Chen-Long Wu)

《北市醫學雜誌》 3卷5期 (2006/05) Pp. 490-505

摘要

目的：臺北市立聯合醫院在面臨總額大餅強力瓜分、點值每況愈下競爭之環境，且面臨內部組織整併及補助款日縮的壓力，於民國93年元月與健保局台北分局簽訂93年版的醫院自主管理合約，本研究檢測醫院自主管理對醫院營運財務面、品質面之效益分析，以及內外部顧客對醫院自主管理認知、感受情形及滿意度調查。方法：以醫院自主管理模式當作實驗的介入，第一部份為比較實施醫院自主管理前、後在醫療服務提供及醫療品質指標分析變化情形；第二部份為醫師、健保局人員及醫院專業人員對醫院自主管理認知、感受情形及滿意度調查，研究工具以結構式問卷來進行，研究母群體為臺北市立聯合醫院7家院區之主治醫師、醫院專業人員及健保局行政人員，回收有效問卷共計有308份，回收率為60%。結果：營運財務面部分，93年度實施自主管理後，其斷頭損失之門診申報點數為112，252，527，住診為34，477，479，共計斷頭點數為146，730，006；醫療品質面部分，七家院區指標未達成總計被追扣點數28，528，385，然就93年與91年七家院區TQIP品質指標相比，譬如死亡率由原本2.02%下降為1.85%，剖腹產率由30.08%下降為25.34%，可見93年品質指標大都是朝正面成長；自主管理認知、感受情形及滿意度調查面部分，醫師對健保制度的知識是非常有限，醫師、健保局人員及專業人員對自主管理均感滿意。結論：本研究建議：(1)健保主政者應立即重視健保醫療費用不足之窘境，紓解健保財務的危機，以保障被保險人的權利；(2)醫院經營管理者考量對醫師人員、醫院專業人員加強健保的相關教育訓練，因應DRGs、未來個別醫院總額預算實施，及早洞悉醫院本身疾病的類型及權值(Case Mix Index)，提供相關方針及策略，以達到個別醫院之最適經營模式；(3)經營決策者應對醫療環境的脈動即時掌握及因應，營造市醫品質管理的組織文化，兼顧到人性化和醫療照護品質的提昇；(4)應積極與基層診所建立醫療資訊平台，減少資源的濫用與浪費，促進民眾的健康。

關鍵字

總額預算支付制度 ； 醫院自主管理 ； 醫療品質指標

並列摘要

Background and Purpose: The purpose of this study was to evaluate the effects on finance, medical quality, members' awareness, attitudes, and satisfaction measured one year after the introduction of the hospital autonomy-management payment system in Taipei City Hospital. Methods: A cross-sectional method was used in the survey during the period from January to December 2004. The medical expenditure claims of seven branches were collected from the Bureau of National Health Insurance (BNHI), Taipei branch, during the year of 2004. Using the above data, we analyzed the changes in medical expenditure payments, medical quality indicator, members's awareness, attitudes, and satisfaction outcomes. The research included 308 members, questionnaires were sent to these individuals by mail. The Chi square test was then used to compare the different groups which are physicians, officers of BNHI and hospital staff. Results: One year after the introduction of the hospital autonomy-management payment system, we found the following: (1) the seven branches payments of medical expenditure claims exceeded 112,252,527 points in outpatient, and 34,477,479 points in inpatient. (2) 28,528,385 points was deducted for the unable to meet the medical quality indicator required by BNHI. (3) Doctors's recognition on Autonomy-Management Payment System were less than hospital and BNHI officers. Conclusion: The study confirms that BNHI directors should have the concern for medical expense insufficiency of health insurance. In addition, the training program for declaring system such as Case Mix Index and medical audit should be enhanced for the physicians and hospital staffs while the coming era of DRGs payment system conducted by BNHI in the near future.

並列關鍵字

global budget system ； self-management payment system ； medical quality indicator