醫院總額支付制度對醫師人力於醫療機構層級間分布之影響

Hospital Global Budget Influences on Distribution of Physician Manpower among Different Medical Institute levels

陳姿君(Tzu-Chun Chen)

指導教授 ： 黃偉堯

長榮大學/健康科學學院/醫務管理學研究所/碩士(2007年)

https://doi.org/10.6833/CJCU.2007.00135

摘要

研究背景：2002年實施醫院總額支付制度，醫院在收入面的成長受到限制，在效用極大化模式下，醫院決策者在考量所提供服務的數量及品質，醫師人力會符合醫院評鑑的基本標準，以減少成本的支出，達到最大化。
研究目的：探討醫院總額支付制度實施後，對醫療機構層級間醫師人力結構的影響。研究問題有二：1.醫院總額支付制度實施後，醫師是否傾向在診所執業？ 2. 醫院總額支付制度實施後，各層級醫院每床醫師數是否會下降？
研究設計：採取事前事後縱斷式的研究設計，研究期間為1999年至2004年。2002年作為分界點，以醫院以2002減1999年作為醫院總額支付制度實施前期；以2004年減2002年作為醫院總額支付制度實施後期。運用魏可遜配對組符號檢定（Wilcoxon Signed Ranks Test），分析醫療機構層級間醫師數與醫師病床比變化。分析單位分別為醫療網65醫療次區域及480家醫院。
研究對象：醫院醫師及診所醫師。
資料來源：衛生署統計室「醫療院所現況與醫院服務量之資料檔」與「臺閩地區人口統計」為主要資料來源。
結果測量：醫院診所醫師增加數差值、醫師病床比差值。
主要結果：醫院總額實施後醫院醫師相較於診所醫師有顯著減少（Wilcoxon Signed Ranks Test, Z＝-2.037，p＜0.05）。以醫院層級分析，整體醫師病床比差值在醫院總額支付實施後有減少，但未達統計上顯著意義（Z＝-1.892，p＞0.01）。進一步，依照醫院評鑑層級區分，醫學中心醫師病床比顯著減少（Z＝-3.295，p＜0.01）；區域醫院（Z＝-1.210，p＞0.1）及地區醫院（Z＝-0.466，p＞0. 1）之醫師病床比減少，但未達顯著性差異。
結 論：醫院總額支付制度實施後，整體診所醫師增加速度大於醫院執業醫師。在醫院層級部分，醫學中心的醫師病床比顯著性的減少，表示醫學中心醫師照護的病床數增加，且醫師有外流至其他層級的情形。

關鍵字

效用極大化模式 ； 醫療機構層級 ； 醫師人力 ； 醫院總額支付制度

並列摘要

Background: When Hospital global budget implemented in 2002, hosptials face the financial contrains. Under the utility maximizing model of hospital behavior, the hospital decision makers would consider the quantity and quality of medical care. Hospitals would pursue the number of physicians meet the minimum standard of hospital accreditation for cost down and utility maximization.
Objectives: To explore Hospital global budget influences on distribution of physician manpower among different medical institute levels. And to examine: 1. did physicians prefer to practice in clinics? 2. did physician-bed ratio decrease after implementing Hospital Global Budget
Design: This study used longitudinal study design with the Before and After comparison. The selected time frame is from 1999 to 2004. Take 1999 to 2000 as the Before stage and 2002 to 2004 as the After stage of Hospital Global Budget. Applied the Wilcoxon Signed Ranks Test to exam the difference of physician distributions among different medical institute levels and physician-bed ratio in hospitals between the before and the after stages. The 65 sub-regions in health area service network and 480 hospitals were as analytic unites, respectively.
Subjects: General practitioners and hospital physicians
Data sources: The data sources were from “Hospital and Clinic statistics” providing by the Health and National Health Insure Annual Statistic Information Service which provides information on physicans among medical care institution, and population are from the Taiwan-Fukien Demographic Fact Book.
Measurement: Differences between the number of general practitioners and hospital physician, and the physician-bed ratio
Result:1. The number of hospital physicians were significant decreased than general practitioners after implementing hospital global budget(Wilcoxon Signed Ranks Test, Z＝-2.037, p＜0.05). 2. For All hospitals, the physician-bed ratio was no significant decreased after implementing hospital global budget(Wilcoxon Signed Ranks Test Z＝-1.892，p＞0.01）. For medical center level, there was significant difference on physician bed ratio(Wilcoxon Signed Ranks Test, Z＝-3.295, p＜0.01), but no evidence on regional(Wilcoxon Signed Ranks Test, Z＝-1.210, p＞0.1) and district hospital level(Wilcoxon Signed Ranks Test, Z＝-0.466, p＞0.1) , respectively.
Conclusion: After implementing Hospital Global Budget, the speed of increasing the number of general practitioners was higher than hospital physicians. For hospital levels, the physician-bed ratio was significant decreased in medical center. The conclusion implicated that physicians might care more beds and outflow to other hospital levels after hospital global budget.
After implementing Hospital Global Budget, the speed of increasing the number of general practitioners was higher than hospital-based physicians.
For hospital levels, the differences of physician-bed ratio was significant decreased in medical center and implicated that physicians might care more beds and physician might outflow to other hospital levels.

並列關鍵字

Utility Maximizing ModeL ； Medical Institute Levels ； Physician Manpower ； Hospital Global Budget.

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