西醫基層總額預算制度對高雄市診所醫師醫療行為及其經營策略與滿意度之影響

Effects of Global Budget on Clinic Physicians’Practice, Management Strategies and Satisfaction

邱俊傑(Chun-Chieh Chiu)

指導教授 ： 毛莉雯

高雄醫學大學/健康科學院/公共衛生學研究所碩士在職專班/碩士(2003年)

摘要

研究目的：
全民健保實施西醫基層總額預算制度對基層診所的醫療生態已經造成重大的影響，本研究藉由分析高雄市西醫診所客觀的健保申報資料與主觀的醫師問卷資料，評估總額前後基層診所門診醫療服務量與醫師醫療處置行為、處方行為、因應策略及滿意度之改變情形。
材料與方法：
以中央健保局合約之高雄市所有西醫基層診所為對象，蒐集其自民國89年7月至91年6月兩年期間健保申報的相關資料，另外針對民國91年高雄市醫師公會會員名冊所登錄之所有基層診所醫師，共906人為對象，利用問卷的方式對所有的醫師作全面的調查，並將所得的資料整理之後，利用SPSS10.0版套裝軟體進行描述性統計及無母數Z檢定與卡方檢定的統計分析，比較西醫基層總額制度實施前後健保申報資料的差異以及問卷資料在醫師醫療行為、因應策略及滿意度的差異比較。
結果與討論：
在客觀的健保申報資料方面，總額前後，每人次平均醫療費用明顯增加，由443元增至464元，其餘醫療服務量都沒有明顯改變。醫師醫療處置行為包括專案率、慢性病率、門診手術率及處方釋出率，在總額之後都有明顯增加。醫師處方行為，除開藥天數明顯增加，由3.9天增至4.1天，其餘每日平均藥費及每人次平均藥費方面，則明顯減少，分別由30.5元減至26.4元及118.8元減至107.5元。
在主觀的醫師問卷資料方面，實際發出問卷數共873份，有效回收628份，有效回收率71.9﹪，問卷資料結果分析，總額之後大部分的評估項目醫師主觀認定「沒有改變」的佔大多數，比例都超過五成，但經卡方檢定之後，發現每日平均看診數與每週工作總時數等主觀評估項目與診所醫師四項基本特質（年齡、執業年限、執業專科科別及專任醫師人數）有明顯相關。
結論與建議：
依本研究之主觀與客觀的資料相互印證，總額支付制度實施對診所醫師的醫療行為、因應策略及滿意度的影響，醫師主觀認定，改變不大，但客觀資料在每人次醫療費用、醫療處置行為及處方行為方面，都有明顯改變，顯示總額制度已慢慢導正診所醫師論量計酬的觀念，改變醫師的醫療處置行為，提高處方的適切性，增進診所醫師因應策略的能力，對西醫基層總額支付制度實施的滿意度也沒下降。建議衛生主管機關應注意醫師投入減少是否影響民眾就醫的可近性與權益；藥品費用減少及醫療處置增加，是否會有虛報或灌水等違法情事發生，或者醫師轉而開立較廉價藥品之行為，而影響民眾就醫的醫療品質；自費診療項目是否浮濫而增加民眾的經濟負擔。並應促進支付標準更合理化，落實專業審查制度更公平化，提昇醫師專業自主性，加強診所與醫院的合作模式，避免浮動點值的失控，導正醫師的醫療行為，以提昇醫療服務的品質與適當性。

關鍵字

總額預算制度 ； 西醫基層診所

並列摘要

Objective：It has made a big change on Western physician clinics after implementing the Global Budget Scheme. The aim of this research is to explore the changes on the quantity of outpatient medical service of clinics and on physicians’ practice, management strategies, satisfaction in the same one year before and after the Global Budget Scheme being inaugurated by analyzing the objective claim data and physician’s subjective questionnaire data in Kaohsiung city.
Materials and methods：Bureau of National Health Insurance Kao-Ping Branch’s File of Outpatient Medical Expense was employed among primary Western physician clinics in Kaohsiung city from July,2000 to June,2002. The other, total 906 clinic doctors registered in Kaohsiung City Medical Association at 2002 were investigated by questionnaires. All of the objective and subjective results are used to compare the changes about the claim data and physicians’ practice, management strategies, satisfaction toward the Global Budget Scheme by statistical program using the SPSS 10.0 software.
Results and discussions：In objective claim data, the average of medical expense per capital increases significantly after implementing the Global Budget Scheme，from 443 to 464 dollars，but the quantity of other medical services do not change significantly. Physicians’ practice including special case rate, chronic disease case rate, outpatient surgery rate and prescription releasing rate all increase significantly. In physicians’ prescription behavior, only the amount of drugs prescribed increases significantly from 3.9 to 4.1 days. The average of drug fee per day and per capital both decrease significantly from 30.5 to 26.4 dollars and from 118.8 to 107.5 dollars separately. In physician’s subjective questionnaire data, total 873 questionnaires were sent to clinics and 628 questionnaires were completed. The response rate is 71.9 ﹪. More than 50﹪physicians answer 「no change」to most evaluation items in the questionnaire. But there are significant correlations between evaluation items and four physician’s characteristics including age, total years of operation, professional expertise and the number of physicians in clinic after taking the questionnaire data into chi-square test.
Conclusions and suggestions：The effects of Global Budget on clinic physicians’ practice, management strategies and satisfaction are not change according to the questionnaire data, but the objective claim data reveal that there are significantly changes in the average of medical expense per capital ,physicians’ practice and prescription behavior. So it changes the medical behavior of clinic physicians by correcting the ”fee-for-service” practice progressively and elevates the appropriateness of prescription and increases the abilities of management strategies and the satisfaction also does not decrease after implementing the Global Budget Scheme. It is suggested that the authority continues to monitor the effect of decreasing medical input by clinic physicians .In addition, the authority also needs to purchase if there are any illegal problems or damage to medical quality or increasing patient’s economic burden due to lowing drug expense, increasing medical practices or non-insurance items. The authority shall promote the payment system more reasonable, the professional examination system more fair, physician’s professional autonomy and the cooperation between clinic and hospital. It also shall try to control floating values, correct physician’s practice and elevate the quality and appropriateness of medical service.

並列關鍵字

Global Budget Scheme ； Western physician clinics

參考文獻

一、 中文部分：

1.呂碧鴻、王英偉、謝維詮（民79）。家庭醫師在全民健康保險級醫療網中

的角色----現在與未來之探討，行政院院經濟委員會。

2.周麗芳、陳曾基（民90），由經濟政策觀點檢視全民健保總額支付制度。

台灣醫界，44（1），45-50。