台灣開放式醫療制度之研析

Analysis of Taiwan’s Open hospital service system

林以祥(I-Hsiang Lin)

指導教授 ： 白佳原

中山醫學大學/健康管理學院/醫療產業科技管理學系碩士班/碩士(2017年)

摘要

台灣醫院服務體系屬於封閉式系統（closed system）。在醫院服務之醫師與醫院彼此有約僱關係，不容許雙重執業（dual practice），即醫師不得在外兼業；另一方面，開業診所醫師亦無法使用醫院的醫療設備治療病患，意即於醫院無住院之特許權（admitting privilege）；且封閉式醫院服務體系中，診所與醫院間無任何聯繫或合作關係，醫療機構所有人員、硬體設備與提供的醫療服務皆隸屬機構醫院直接經營。因此，醫院間彼此獨立，各項資訊與軟硬體設備亦未流通，病人或社會對不同規模醫院會給予個別評價，尤其新治療技術大多出現於規模較大之醫院，很難令人相信規模不同之醫院會有相同的服務品質，甚至因醫院亦提供門診服務，使兩者間頗具競爭；而醫院醫師值班議題、醫療人力不均及醫療資源城鄉差距之議題亦備受關注。此外，雖然目前台灣亦有醫院特約醫師但給予特約醫師之給付低且申請不方便，故很少醫師願意去醫院執行醫療行為或服務。
美國的開放式醫療體系（open staff system），除了少數的退伍軍人醫院及公立醫院之外，醫院沒有主治醫師亦沒有門診部門，如有門診部，通常是另立門市之建築物，甚至要開車才能到，稱之為「診所」，所有醫師均為開業醫師（類似台灣的開業醫師），醫院與醫師為簽約之合作關係，醫院不須給付薪水給醫師，保險機構會將保險給付直接支付至醫師之帳戶。
依據美國開放式醫療制度運作模式，台灣醫院可與開業診所醫師簽約，開業醫師每年與一至三間醫院簽約，而簽約內容及所需互相配合之醫療服務事項皆由開業醫師與醫院協調達成共識，讓開業醫師之病患需接受進一步治療時轉介至醫院，並由該開業醫師負責該病患之治療及至病房會診等醫療服務，同時，醫院在和開業醫師簽約時亦可協調關於當急診部門人手不足時可調動或聯絡開業醫師支援，以解決醫療人力不足之狀況。
台灣若實施開放式醫療制度預期能有效解決醫療體系目前所遭遇之挑戰，在醫師方面，可使得醫師在醫療技術上不斷的進步、並可使用較新的醫療儀器設備；同時，可藉由開業醫師與醫院簽訂特約而讓原醫院醫師不足而造成值班過量的問題得到紓困；在醫院方面，值班問題和急診醫師作業之問題皆可改善，使得醫院不會出現醫師人力不足之狀況，醫院則可有更多的專科醫師會診；對民眾及患者而言，輕度疾病患者可就近至診所就診，但若病情轉為嚴重亦可由原診所醫師將病患至就近醫學中心就醫治療，此舉可使患者在疾病的發生至病情進展各階段由同一位醫師診治，改善病患或一般民眾之醫療照護品質，以期更有效率的減緩病程發展及預防疾病發生，故對於整體醫療資源可更有效的運用，醫療費用則可大幅降低，以減少醫療成本及社會負擔。

關鍵字

封閉式醫療制度 ； 開放式醫療制度 ； 診斷關聯群 ； 醫療人力資源 ； 美國醫療保險

並列摘要

Taiwan's hospital service system is a closed system. Physicians working in hospitals have a contractual relationship with hospitals. They do not allow dual practice. On the other hand, physicians in open clinics cannot use hospital medical equipment to treat patients. Clinics and hospitals have no any contact or cooperation between all medical institutions, hardware equipment and medical services are provided by the institutions, by the hospital directly operating the entire organization. Therefore, hospitals are independent of each other, the information and hardware and software equipment is not in circulation, the patient or the community of hospitals of different sizes will be given individual evaluation, especially in the new treatment technologies are mostly large hospitals in the social impression, It is difficult to convince people of different sizes of hospitals to have the same quality of service, or even to provide out-patient services in hospitals. The issue of hospital doctors on duty issues, medical manpower inequality and medical resources gap between urban and rural issues of concern.
The open staff system in the United States, with the exception of a few veterans and public hospitals, does not have an attending physician or an outpatient department. If there is an outpatient department, it is usually a separate building. Hospital does not have to pay wages to the physicians; the insurance agency will directly pay to physicians.
According to the open system of the US, Taiwan hospitals can contract with the opening clinic physician, practitioners signed with one to three hospitals each year to pay the signing of the contract, and the contents of the contract and the required medical services by the practitioners and practitioners Hospital coordination to reach a consensus, so that patients with open practitioners to be referred for further treatment to the hospital, the practitioner is responsible for the treatment of patients and ward consultations and other medical services, and hospitals and medical practitioners can also be signed Coordinate the provision of medical assistance when the emergency department is understaffed or contact the physician support to resolve the problem of medical manpower shortage.
If the implementation of open health care system in Taiwan is expected to effectively address the current challenges facing the health care system to improve the shortage of doctors in hospitals caused by over-duty problems, improve the quality of medical care for patients or the general public in order to more effectively slow down the course of development and prevention of disease, so the overall medical resources can be more effective. Medical costs can be significant reduce.

並列關鍵字

Closed medical system ； Open medical system ； Diagnosis Related Groups（DRG） ； Medical Human Resource ； American Health Insurance

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