健保醫院總額預算實施對急診專科醫師人力配置及急診利用相關因素趨勢分析:以南部某醫學中心為例

本研究是選定南部具有1700床的醫學中心於民國92年至101年間急診室就診之病患進行研究，2003年健保醫院總額介入使門診、住診費用比例為50：50。2004年門住診費用比例變更為45：55。其研究是介入後年度的項目變化包括就診科目、檢傷分類、年齡、留置時間、疾病類別、門診轉急診住院病患的檢傷類別及急診留置時間等重要數據。我們利用檢傷嚴重度來分析醫師的工作量，不同的專科醫師人力比率是否帶來不同的工作壓力，據以設定專科與非專科人力比例，作為日後人力支援的重要參考數據。本研究發現從93~94年檢傷一、二級病患佔有50%~70%，至95~98年間下滑至37%，而三、四級病患則從93年的30%左右一直上升至98年的61%。從上述變化可知從93至98年間疾病嚴重度明顯下降，其來源可能大量內科病患至急診就醫而其中部份是非緊急病患，所以造成疾病嚴重度被稀釋。健保資源利用不均，由於需求供給問題(demand and supply)健保對醫院端使用總額制度減少浪費，但對病患未有限制造成大量非急診病患就醫形成醫院醫療品質下降及資源浪費。因應上述問題對於非急診病患是否予以約束並開放急性門診以緩和急診壅塞問題。

關鍵字

醫院總額；檢傷分類；疾病嚴重度；非緊急病患；急診專科人力

並列摘要

The purpose of this study was to investigate the knowledge, practice and analyze the trend of emergency service utilization and the physician staffing under the affection of Taiwan’s global budget. Subjects were recruited by a cross-sectional survey from a medical center located in Southern Taiwan. With the hospital global budget started in 2003, the ratio of hospital OPD to admission use is changed from 50:50 to 45:55. The limited usage of OPD by patients let they preferred to visit emergency department to have further medical care. Due to the National Health Insurance provide throughout medical care to all patients, so emergency crowding happened thereafter. This study is to investigate the change of severity of disease, change of the triage level and the inadequate of staffing of emergency physician were found. The change of level 1 and 2 of triage system in 2004 from 50~70% to 37% in 2009 and also the level 3 and 4 changed from 30% to 61%. Due to the severity of disease is changed and more medical resource is needed in emergency department. Crowding of emergency department is happened due to demand and supply through the policy of the hospital global budget. Non-emergency or non-urgency patients are the major problem of the emergency crowding. The National Health Insurance is needed to investigate the cause of the problem and provide the necessity solution.