以系統動態學方式探討在少子化危機及全民健保政策下台灣之兒科醫師人力規劃

Taiwan Pediatric Workforce in an Era of National Health Insurance and Nadir Birth Rates: A Systemic Thinking Approach

吳美環(Mei-Hwan Wu)

指導教授 ： 黃崇興

共同指導教授 ： 余峻瑜

國立臺灣大學/管理學院/商學組/碩士(2012年)

https://doi.org/10.6342/NTU.2012.01846

摘要

背景：兒科醫學是己有200年歷史的醫學專科，兒科醫師是照顧兒童(0-18(20)歲)的內科醫師。台灣的少子化問題開始於1986年，雖在1990-1997年略有緩解，但在近十五年，卻日益厳重。兒童人口日益減少人口老化問題逐漸浮現。在台灣，國家級全民健康保險1995年開始，醫療變為單一醫療給付制度。日漸減少的兒童人口，在單一醫療給付與全民健保起始偏低的兒童醫療給付的限制下，更造成兒童醫療收入遠低於醫療常態。不但減低醫學院畢業生選擇小兒科住院醫師訓練計畫的意願，即使己在執業的小兒科醫師也有轉業的狀況。然而，兒科醫師的養成是需要射時間的，此種兒科醫師人力的變化是否適當反應兒童醫療需求量的變化，亟需澄清。因此本研究擬以分析概念探討兒童醫療需求與兒科醫師人力狀況的相互影響，並以系統動態學方式建立數學模型，以為預測變化之根據。
方法:本研究之資料收集來自國家衛生與內政資料庫，醫師人力資料來自專科醫學會及全國醫師聯合公會。系統動態學源自Jay Forrester的學說，情境分析與數學模型建立及電腦模擬則採用Vensim電腦軟體。
結果:2010年台灣的兒童人口約為460萬，兒童與兒科醫師比為1762，由醫療型態類似的美國、日本及台灣資料迴歸分析，嬰兒死亡率與兒童與兒科醫師比成正相關 (p=0.005, r2 =0.989, 兒童與兒科醫師比= -484+545.5*嬰兒死亡率)。依此、台灣嬰兒死亡率若要維持目前數值(4.5/1000 live births)甚或達到聯合國千禧年目標(3.91/1000 live births)或達到目標值日本嬰兒死亡率(2.5/1000 live births), 姑且不論醫療複雜度之增加，台灣的兒童與兒科醫師比需求分別為1762，1649 及1153。台灣兒科醫師的養成、有證照後的生涯規劃、執業的兒科醫師生涯軌道的改變等皆可以系統動態學的各種變因、迴路及流程來反應。且由各項変因之迴路，可看出正向迴路及平衡迴路的影響，並藉以修正。由人口群及兒科醫師養成生涯的數學模型，當輸入歷史值及預測值後，即可預測兒童人口及醫療需求量以及兒科醫師人力未來的變化。我們的預測兒科醫師人力情境的狀況有二；目前狀況因政策誘因而變好及因無政策誘因而狀況變壞。由電腦模擬發現，若狀況因政策誘因而變好，在2012年兒科醫師數己呈不足來維持目前台灣嬰兒死亡率，但2014年之後可因兒童人口變少而填補到位，但在2018年又不足，且不足醫師數逐年擴大。若要達到聯合國千禧年目標，不足醫師數更多。若兒科醫師人力因無政策誘因而狀況變壞，在2012年兒科醫師數己呈不足，之後即使兒童人口變少亦無法填補到位，且不足醫師數擴大極快。然而、二種兒科醫師人力狀況，無論在那年皆不易達成目標值嬰兒死亡率。
結論:在少子化厳重、單一醫療給付制度的台灣年代，兒科醫師的養成己過度反應少子化的人口變化及醫療量。以系統動態學概念及模型電腦模擬可協助預測醫療量需求及兒科醫師養成量，且可因誘因變改變而重覆模擬與修正預測。依目前狀況預測，十多年後將有嚴重之短缺現象。相關之政策誘因是必要的。

關鍵字

系統動態學 ； 兒科醫師 ； 人力規劃

並列摘要

Introduction: Pediatrics is an established specialty for more than 200 years. Pediatricians take care of the illness of pediatric population (aged 0-18 years) and the child-to-pediatrician ratio is associated with child health indexes. In Taiwan, in an era of declining birth rates and single health care payer (national health insurance) system, the pediatric workforce is changing and may overreact to the declining demand. The overreaction would be further amplified due to the delay of workforce maturation.
Methods: We extracted the data of population and pediatric workforce from national and academic society databases. A systemic strategic thinking was completed by adopting a systemic dynamic approach (commercial software, Vensim).
Results: The child-to-pediatrician ratio in Taiwan was 1742/1000 live births in 2011 and was associated with infant mortality (p=0.005, r2 =0.989, child-to-pediatrician ratio = -484+545.5*infant mortality). The child-to-pediatrician ratio for Millennium Development Goals (MDG) (3.91/1000 live births) and target (Japan, 2.50/1000 live births) levels of infant mortality was estimated at 1649 and 1153, respectively. The data of workforce in 2010s already showed an overreaction. By strategic systemic thinking, the scenario of pediatric health care could be depicted by loops of reinforcement and balance loops. Specific population SD mathematic models predict that the base pediatric population in Taiwan would decrease steadily until 2020s and the fertile age adults would also decrease and worsen the number of newborns. The SD model of workforce also predicts the maturation stages and the supply of pediatricians in each year. The gaps between the desired pediatricians for the base, MDG and target deficits would appear in late 2010s, and was present in all years for the target level of infant mortality.
Conclusions: In an era of low birth rate, aging population and single payer health care system, the trend of pediatric workforce had been modified and overreacted due to time delay in Taiwan. To elucidate the complex interaction of declining pediatric population (decreasing demand) and the delay in pediatrician workforce career path, we developed SD models for both population and workforce. Simulation validated the effectiveness. Severe workforce shortage would appear in late 2020s in spite of decreased pediatric population. With intervention, simulation by SD models may predict the effectiveness and provide sound evidence for policy makers in national health care.

並列關鍵字

System dynamics ； pediatrician ； workforce

參考文獻

1. Mahnke CB. The Growth and Development of a Specialty: The History of Pediatrics. Clin Pediatr. 2000;39:705-14.

2. Burke EC. Abraham Jacobi, MD: the man and his legacy. Pediatrics. 1998;101:309-312.

3. Althouse LA, Stockman JA. The Pediatric Workforce: An Update on General Pediatrics and Pediatric Subspecialties Workforce Data from the American Board of Pediatrics. J Pediatr. 2011;159:1036-40.e3. Epub 2011 Sep 9.

6. Nomura K, Inoue S, Yano E. The shortage of pediatrician workforce in rural areas of Japan. Tohoku J Exp Med. 2009;217:299-305.

7. Goulston KJ, Dent OF. Trends in the specialist workforce in paediatrics in Australia, 1981-1997. J Paediatr Child Health. 2000;36:306-12.