原住民地區實施醫療給付效益提昇計畫之探討－以屏東縣春日鄉為例－

Exploration on the Implementation of the Medical Benefits Effect Upgrade Plan in Aboriginal Areas --An Example of Chun Jih Ksiang--

林進川(Chin-Chaun Lin)

指導教授 ： 邱亨嘉

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

健保局為改善離島地區醫療資源缺乏，交通不便造成就醫困難的情況，分別於台灣地區各山地鄉衛生所分段實施整合性醫療服務(IDS)，而春日鄉衛生所於九十一年二月一日辦理整合性醫療服務(IDS)計畫。本研究主要目的在於評估九十年二月一日至九十二年一月卅日承作模式介入前後，對於春日鄉居民在就醫可近性、滿意度及醫療利用等方面的差異，並探討影響春日鄉居民就醫的因素，進而提供健保局作為改善各山地鄉承作IDS方案的參考。
　　本研究將古華村、士文村、力里村為非承作IDS計畫組，而有相同條件但實施整合性醫療服務(IDS)的春日村、七佳村、歸崇村為IDS組。以Aday and Andersen的醫療可近性架構為理論基礎，並依據Penchansky and Thomas所提出之滿意度評估指標，做為制定本研究問卷之理論基礎。研究資料來源分為初級和次級資料，初級資料分為一般民眾問卷（有效樣本437戶）、醫護人員問卷（20人）及意見領袖問卷（13人）。次級方面則收集非承作IDS及IDS計畫實施前後一年的健保申報資料及衛生室的相關健康資料，以便統計分析計畫實施前後醫療利用及費用支出的差異。
　　研究結果發現，實施整合性醫療服務(IDS)於春日鄉衛生所的門診利用次數從介入前的平均每人每年8.16次增加為14.52次。承作IDS各村門診資料從介入前的2808人增加3972人，稍顯著改善。村外就醫率則以介入前後從46.2%降為35.1%稍為改善。醫療費用方面則鄉內各村都有顯著的增加，費用成長的主因在於用藥金額的成長，門診人次增加。此外，承作地區的居民對於衛生室的整體滿意度都在平均42.7%以上，而最不滿意支援醫師輪替太過頻繁、上班遲到、語言溝通問題，無法掌握居民病情。實施整合醫療服務計畫的非承作IDS的居民鄉內門診人數從3000人增加為4092人，而每人次費用以及村外就醫比率在IDS介入前後稍有顯著改善。春日鄉各村居民對於承作計畫增加護理人員數感到滿意，但支援專科醫師的上班遲到以及後送運輸不便，仍讓居民不滿意。
　　整體而言，不管是非承作IDS計畫或IDS計畫的各村，皆有超過89.5%居民覺得對就醫方便性有幫助，尤其對於鄉內行動不便的老年人口。同時對於提高預防保健的受檢率方面有非常良好的成效。因此，此種承作模式的階段性任務，改善春日鄉居民就醫可近性的問題應是達成。本研究建議有必要24小時的醫師於春日鄉服務，並且改善衛生室的醫療設備以及支援足夠的專科巡迴醫療，對於提高村內就醫比率以及滿意度會有所助益。而近一步應針對居民的疾病來做管理及加強預防保健的服務與教育，讓全民健保能夠確實的照顧到原住民的弱勢族群。
關鍵詞：原住民、整合性醫療服務、滿意度、可近性、醫療利用率

關鍵字

原住民 ； 整合性醫療服務 ； 滿意度 ； 可近性 ； 醫療利用率

並列摘要

For the Purpose of improving the lack of medical resources and the difficulty in doctor consultation resulting from the inconvenient transportation in the outlying islands, the Bureau of National Health Insurance implements stage by stage the
Integrated Delivery System (IDS) in the health station of each aboriginal societies throughout Taiwan region. Accordingly, the Health Station of Chun Jih Hsiang, Pingtung County carried out the IDS program on February 1, 2002. This study is mainly designed to evaluate the difference in such aspects of the doctor consultation accessibility, the degree of satisfaction and medical utilization of the residents in Chun Jih Hsiang before and after the involvement of the undertaken module between February 1, 2001 and January 30, 2003. In addition, it explores what factors affect the doctor consultation of the residents in Chun Jih Hsiang, which will be furthermore
provided to the Bureau of National Health Insurance for their reference in improving the IDS project undertaken by each aboriginal society.
In this study, Ku Hua Village, Shih Wen Village and Li Li Village are classified as the non-IDS-undertaken group, while Chun Jih Village, Chi Chia Village and Kuei Chung Village which with the same conditions implement the IDS plan instead are categorized as the IDS-undertaken group. The theoretical basis of design for this study questionnaire is founded on the medical accessibility structure brought forward by Aday and Andersen as well as the satisfaction degree evaluation index proposed by Penchansky and Thomas. The sources of research information are divided into primary and secondary data. The primary data includes the general public questionnaire (valid sample 437 households), medical nursing personnel questionnaire
(20 persons) and opinion leader questionnaire (13 persons). As for the secondary ata, we collect the non-IDS-undertaken and the IDS-undertaken health insurance reporting information and the relevant health information of the health room one year before and after the implementation of the plan, so that we can calculate and analyze the variance of the medical utilization and expenses payment prior to and after the plan implementation.
The study results show that the number of the out-patient consultation utilization in the Health Station of Chun Jih Hsiang increases from 8.16 at average per person per year before the plan involvement into 14.52 in terms of the IDS implementation. The out-patient consultation information of those IDS-undertaken villages increased from 2808 persons before the involvement of the plan to 3792 with no significant difference. The rate of doctor consultation outside of the village shows the most drastic decrease from 46.2% to 35.1% before and after the plan involvement. As far as the medical
expenses are concerned, remarkable increase appears in each village. The main cause for growth of the expenses lies in the growing medication amount and the increasing out-patient consultation person-time number. Besides the overall satisfaction degree of the residents in Chun Jih Hsiang towards the Health Station averages over 42.7%. They feel most dissatisfied with the over frequency of shifts of the supporting doctors, their being late to word, the language communication problem ad their failure in controlling the resident's diseases. The out-patient consultation number of the non-IDS-undertaken residents in the village for the implementation of the IDS plan increased from 3000 to 4092. Moreover the expenses per person and the doctor consultation rate outside of the village both assume outstanding change before and after the involvement of the IDS. The residents in each village of Chun Jih Hsiang feel satisfied at the increase of the nursing personnel in the undertaken plan. However they still feel dissatisfied with the backup specialist physician who work late and the inconvenient follow-up transportation.
Generally speaking, no matter what villages are non-IDS-undertaken or IDS-undertaken, over 89.5% of the residents think the plan is helpful to the doctor consultation accessibility, especially for those wheelchair-bound old-age population in
the country. In the meantime, it makes excellent effects on the promotion of the examination rate in the preventive health. In consequence, the stage-by-stage mission of such an undertaken module really improves the problem of the doctor consultation accessibility for the residents of Chun Jih Hsiang. This study suggests that physicians be required to serve in Chun Jih Hsiang for 24 hours. And the medical facilities of the Health Station should be improved with the fully-supported specialist itinerary medical treatment, which will be conducive to raising the in-village doctor consultation
rate and the degree of satisfaction. Next, we should manage the diseases of the residents and reinforce the service and education in the preventive health in order that the national health insurance can really benefit the deprived aboriginal groups.
Key Words: Aboriginal, Integrated Delivery System, Degree of
Satisfaction, Accessibility and Medical Utilization
Rate

並列關鍵字

Aboriginal ； Integrated Delivery System ； Degree of Satisfaction ； Accessibility and Medical Utilization Rate

參考文獻

中文部分

01.中央健康保險局。(民85)。全民健保實施二年評估報告。

02.中央健康保險局。（民87）。偏遠地區健康

03.中央健康保險局。(民88)。全民健康保險山地離島地區醫療給付效益提昇計畫（修正版）。

04.王惠玄。(民88)。桃園縣復興鄉居民醫療保健資源使用調查、滿意度暨因素分析。行政院衛生署委託研究計劃。