總額支付制度下同儕制約不當運用對牙醫師行為模式影響之探討

健保開辦後，由於醫療可近性的改善，民眾相當滿意。不過大家所關心的是醫療體系的整合、及費用控管，在總額試辦後，雖然限制了費用成長，也提供了財務保障。而這兩者均會造成醫療提供者惰於提昇品質、更新技術或限制新醫療提供者進入。因此如何確保品質、滿足醫需、改善醫源的分配，則成為醫界刻不容緩的課題。因此本研究是就同儕制約對牙醫師看診行為的影響是否能夠達到上述的目標做一些探討。利用檔案分析探討全民健保牙醫門診總額高屏分區委員會（以下簡稱保委會）自主性管理對牙醫師看診行為或申請給付行為的影響，滿足民眾對醫需的要求。並將同儕制約對牙醫師醫療行為變化作進一步的探討。本文研究材料包括:(1)全區與健保高屏分局簽約之基層醫師(不包括醫學中心、區域醫院、地區醫院)。(2)87年7月至91年12月所有牙醫師申報健保數據的原始資料。所應用的方法為 (1)高服務量與全基層院所之追蹤分析。 (2) 高服務量醫師申報點數變化之相關因子的分析根據研究結果:醫師的服務量下降。包括診療日數、病患數、就診人數、每人就診次數、每日就診次數等均呈下降。其中響診所產值最大的是根管治療的佔率及點數，其次是牙體復形的佔率及點數，這兩者的相關係數(Spearman Rank Correlation) 分別為0.8725及0.8681。根據上述研究結果，建議:運用檔案分析輔助專案審查，進一步研擬試辦家庭牙醫師制(即論人計酬制)。關健字：同儕制約總額支付制度論人計酬制

關鍵字

同儕制約；總額支付制度；論人計酬制

並列摘要

After the inauguration of NHI(National Health Insurance), people are satisfied with the improvement Currently the main concern stemming from ordinary people is on both the integration of different medical systems and unified management of medical expenses. Despite the fact that after the execution of GBS(Global Budget System) medical expenses have been controlled and limited and that more and more financial safety arise, some experts are worried about the degradation of the quality concerning doctors’ treating their patients, the rejection from the doctors of skill renewal, and the limitation of new medical providers. Therefore, how to reassure dental service quality, how to meet dental healthy care needs and how to improve the distribution of dental healthy resources become a critical topic among medical fields. This study is to do researches on whether or not peer conditioning will have great influence on dentists’ medical behavior. In the research, file analyses are used not only to study the dental behavior of those dentists who practice their medicine in Kaohsiung and Pingtung area but also to examine how they apply for dental expenses from NHI. Also, the research will make further analysis of these dentists’ medical behavior. Material: a. the doctors who are signed to the Branch of Kaohsiung-Pingtung Area, NHI, and who are excluded in medical centers, local teaching hospitals, and local clinics b. the original data which range from July, 1998 to December, 2002, Methodology: a. the follow-ups and analyses of all local hospitals and those clinics where they are often visited by patients. . b. the analyses of relative causes resulting from the application data issued by high workload dentists Results: a. the low quantity of medical service among all clinics b. the fewer days of dentists’ office hours. c. the fewer patients d. the lower frequency of using NHI card per day and per person e. the factors that affect the running of dental clinics are the percentage of endodontics treatment and the percentage of operative dentistry, whose rank correlations are o.8725 and 0.8681 Suggestion: The usage of professional examination aided by file analyses should come into effect. Next, the idea of capitation payment should be taken into account and tested.