牙醫及中醫實施全民健康保險家庭醫師整合性照護制度之可行性研究－以高屏地區為例

背景：推動家庭醫師制度及建構社區醫療體系為後SARS時期國家基層醫療體系改造的重要目標。中央健保局也積極推動家庭醫師整合性照護制度，以健康管理及論人計酬制度，提供全人健康照護，使預防保健和社區醫療得以落實。目的：(1)探討牙醫師及中醫師對家庭醫師制度相關政策的瞭解程度。 (2)探討牙醫師及中醫師對牙醫及中醫之基層醫療功能、符合家庭醫師型態、實施健保家庭醫師整合性照護制度之認同程度。方法：以高屏地區與中央健康保險局有特約關係的執業牙醫師、中醫師為研究母群體，牙醫師(1381位)、中醫師(568位)，採用分區分層系統取樣法選出牙醫師400位、中醫師200位為研究樣本，進行橫斷式郵寄問卷調查，所得資料利用JMP統計軟體進行資料統計分析。結果：研究結果發現63.4%牙醫師有實施口腔定期檢查，16.1%牙醫師有建立家庭病歷，37.5%牙醫師有參與社區醫療服務，53.7%牙醫師有實施轉診，72.6%牙醫師有實施口腔衛生教育。牙醫師對於家庭牙醫師整合性照護制度認同程度較高51.3%(平均分數3.41)，認知程度較低25.3%(平均分數2.71)，實施認同度50.5%（平均分數3.41），參與意願42.5%(平均分數3.28)，總額支付制度瞭解程度66.1%(平均分數3.69)，其中以男性、40歲以上年齡層、執業20年以上、在鄉鎮及縣轄市執業及自行開業之牙醫師在照護制度之認知與認同程度較高，呈現統計上的顯著差異。中醫師對於家庭中醫師整合性照護制度認同程度較高61.6%(平均分數3.69)，認知程度較低26.5%(平均分數2.87)，實施認同度63.0%(平均分數3.70），參與意願54.8%(平均分數3.63)，總額支付制度瞭解程度56.8%(平均分數3.55)，其中以40歲以下年齡層、執業10年以下、學士後中醫學系、在都會區執業之中醫師在照護制度之認知與認同程度較高，呈現統計上的顯著差異。結論：根據本研究在牙醫和中醫之基層醫療功能、符合家庭醫師型態和實施健保家庭醫師整合性照護制度三項，分別得到68.8%，52.7%，50.5%牙醫師和73.3%，62.6%，63.0%中醫師之認同，因此，推論牙醫及中醫實施健保家庭醫師整合性照護制度具可行性。但家庭醫師制度相關政策的認知程度（牙醫師25.3%，中醫師26.5%）較低，因此，建議主管單位在健保政策形成的過程中必須規劃完善的配套措施及舉辦宣導說明會，讓醫事人員充分瞭解健保政策之實施內容及目的，以促成整合性照護制度提供民眾口腔預防保健、口腔醫療照護；養生預防保健、中西醫結合門診住院之全人醫療照護模式，達成中、西、牙基層醫療社區化的目標。

關鍵字

家庭中醫師整合性照護制度；家庭醫師整合性照護制度；家庭牙醫師整合性照護制度；論人計酬支付制度

並列摘要

Background: The campaign of family physician system and establishment of community health system became the top priorities for the reform of Taiwan’s primary care delivery system in the post SARS era. In order to provide holistic health care to the residents and reinforce preventive medicine as well as community health, the Bureau of National Health Insurance (BNHI) advocated family physician integrated care program (FPICP) aggressively, by developing the mechanisms of health management and capitation. Objective: The purposes of this study were: 1) to investigate dentists and traditional Chinese medical physicians’ recognition of the policy of family physician system; and 2) to examine dentists and traditional Chinese medical doctors’ consensus on the functions of primary care, the ideal model of family physician system, and the implementation of NHI family physician integrated care program. Methods: The study population was 1381 dentists and 568 traditional Chinese medicine physicians who contracted with BNHI Kao-Ping Precinct. Of which, 400 dentists and 200 traditional Chinese medicine physicians were selected as study samples, using stratified systematic sampling technique. A cross-sectional self-administered questionnaire was mailed to the subjects. JMP statistical software was utilized in the process of data analyses Results: The findings indicated that 63.4% of the dentists practiced periodical oral check-up; 16.1% of dentists established dental record of patients’ family; 37.5% of the dentists participated in community dental service, 53.7% of the dentists referred patients to their colleagues; 72.6% of the dentists offered health education service of oral hygiene. The percentages of acceptance, cognition, practicability, and willingness of participation in family dentist integrated care system among dentists were 51.3, 25.3, 50.5, and 42.5% respectively. Sixty-six percent of the dentists reported that they understand the global budget payment system. Male dentists aged over 40, with more than 20 years of experience, and practice dentistry in rural areas tended to have significantly higher levels of acceptance and cognition than their counterparts. In terms of traditional Chinese medical physicians, the percentages of their acceptance, cognition, practicability, and willingness of participation in family Chinese physician integrated care system among were 61.6, 26.5, 63.0, and 54.8% respectively. Approximately fifty-six percent of the Chinese physicians reported that they understand the global budget payment system. Chinese physicians aged less than 40, with less than 10 years of experience in practice, obtained the second bachelor degree in Chinese medicine, and practice Chinese medicine in urban areas tended to have significantly higher levels of acceptance and cognition than their counterparts. Conclusion The majority of dentists and Chinese medical physicians concurred their functions in primary health care, the ideal family physician model, and the implementation of NHI family physician integrated care system. Therefore, the findings of this study support the feasibility of NHI family physician integrated care system, in terms of dental and traditional Chinese medical care. However, only one-forth of the subjects understood the policy of family physician system. In order to promote the FPICP and achieve the objectives of community-based primary care and holistic health care, NHI officials should establish a decent strategic plan with series of action plans, invite primary care givers to the conferences and meetings held in the precincts regularly, and open-up the two-way communication channel between caregivers and the third party payer. Key words: family physician integrated care system, family dentist integrated care system, family Chinese medicine physician integrated care system, capitation payment system