基層醫療實施論人計酬支付制度之可行性探討

A Study on the Feasibility of Capitation Payment System in Primary Care

許銘恭(Ming-Kung Hsu)

指導教授 ： 林恆慶

臺北醫學大學/公共衛生暨營養學院/醫務管理學研究所/碩士(2003年)

摘要

全民健保自民國八十四年實施以來，由於醫療費用不斷上漲，因此支付制度之合理性一直為各方所關注，健保局於近幾年來陸續推動論病例計酬支付制度、牙醫總額支付制度、西醫基層總額支付制度、醫院總額支付制度等，這些政策對醫療費用的抑制都有其實質成效。 而在總額支付制度之下，論人計酬支付制度亦為健保局改革之重要措施，台灣目前尚無真正的論人計酬支付制度，近來衛生署有意從基層醫療開始推動論人計酬支付制度，因此本研究想在此制度實施前，以問卷調查的方式預先了解基層開業醫師對論人計酬支付制度的看法及參與之意願， 本研究之研究目的可分為以下三點： 一、瞭解基層開業醫師所需要的論人計酬支付模式為何。 二、瞭解基層開業醫師參與論人計酬制度之意願及態度。 三、探討論人計酬制度實施後，基層開業醫師認為對醫療服務可能造成之影響。 本研究共發出1,022份問卷，問卷回收率21.14％，其研究結果如下： 一、24％醫師表示瞭解論人計酬支付制度之實質內涵，38％表示不瞭解。 二、僅有19％醫師傾向願意參與論人計酬支付制度，顯示現階段在台灣基層醫師對論人計酬的接受程度仍然不高。 三、論人計酬下基層醫師偏好之模式為由家醫科及內科醫師來擔任家庭醫師，並與健保局簽約，負起守門員的角色。每位醫師負責1,001-1,500位民眾之健康照護，並由家庭醫師負起轉診之責任。健保局給付醫師每位民眾每月之醫療費用應僅包含一般性門診照護之費用。在民眾選擇家庭醫師的需求面上，基層醫師認為應由民眾在不受區域限制的情況之下，自由選擇其所信任之醫師為家庭醫師及受轉醫師。另外，論人計酬支付制度之下，應該設立停止損益機制以避免醫師過度虧損。 四、影響基層醫師參與意願之相關因素中，受人雇用之醫師參與論人計酬意願的機率高於與人合夥及單獨執業醫師。較同意給藥天數減少、預防保健服務增加及各專科醫師間互動增加等選項的醫師有較高的機率願意參與論人計酬，而較同意整體醫療品質下降及醫師會選擇較具成本效益的醫療服務等選項的醫師，有較低的機率願意參與論人計酬。 本研究建議衛生主管機關將來推動此一制度時，能以美國之實施經驗為借鏡，並以控制成本及增加預防保健服務二項益處為宣導重點，擬訂相關之配套措施，如此不但能節省醫療資源，且可以增進民眾健康之福祉。

關鍵字

論人計酬支付制度 ； 基層醫師 ； 守門員

並列摘要

Because medical expenditures have been steadily increased since the implementation of the National Health Insurance in 1995, the rationality of payment systems draw lots of attention by all players in the healthcare industry. The Bureau of the National Health Insurance (BNHI) gradually implemented case payment system, dental global budget system, global budget system for primary care, and global budget system for hospital in the past few years. These payment systems have all demonstrated their ability in containing the escalating medical expenditures. Capitation payment system was also proposed by the BNHI as an important reformed strategy under the global budget system. However, capitation payment system has not been implemented in Taiwan to date. The Department Of Health plans to initiate the capitation payment system on primary care. Therefore, this research was proposed to explore primary care physicians’ opinions and willingness to participate in capitation payment system before the payment system is officially implemented. Three research purposes of the research are following: 1. To understand what capitation model is preferred by primary care physicians. 2. To understand primary care physicians’ willingness and attitudes toward participating capitation payment system. 3. To explore the possible impacts of the implementation of capitation payment on medical services from the perspective of primary care physicians. A total of 1,022 questionnaires were mailed and yielded a response rate of 21.14%. The results of the research are as follows: 1. Of the sampled physicians, 24% understood capitation payment system and 38% do not. 2. Only 19% of the sampled physicians had a tendency to participate in capitation payment system. It indicates that capitation payment system was not highly accepted by primary care physicians in Taiwan. 3. With regard to the model of the capitation system, the sampled physicians preferred family physicians and internalists to be family physicians and served as a gatekeeper by making contract with the BNHI. Every doctor should be responsible for providing health care to 1,001-1,500 enrollees. The medical services reimbursed by the BNHI should only be limited outpatient services. On demand side, the sampled physicians thought that people should be free to choose any available family doctors without any area constraints. In addition, a stop-loss insurance system should be provided to avoid the bankruptcy of doctors under the capitation system. 4.The relative factors that influenced the willingness of primary care physicians to participate in capitation payment system were as follows: physicians who were employed were more likely to participate in capitation system than partnership or solo practice physicians. Physicians who were more agreeable the number of medication days, increasing preventive health service and increasing interaction among all professional doctors had more willingness to participate in capitation system. Physicians who were more agreeable decreasing the whole medical quality and choosing more cost efficient health services had less willingness to participate in capitation system. The researcher suggests that health authorities can learn from the US experiences in practicing capitation before carrying out the payment system in Taiwan. The health authority also propagates the payment system with controlling cost and increasing preventive health services along with forming a complete set. Thus it can not only save medical resources but also promote the health of people.

並列關鍵字

capitation payment system ； primary care physician ； gatekeeper

參考文獻

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