背景:從以論量計酬為主轉變成以論病例計酬為主的支付制度提供許多的優點。然而,當全面採用論病例計酬制度的可能性提高時,卻相對地使人們擔心全面性的實施論病例計酬制度將會遇到許多的困難,特別是在醫師的醫療行為模式方面。本研究的主要目的,即在探討醫師的特性與實施論病例計酬制度下其所遭遇困難間之關係。 方法:本研究使用由Lin及Amidon所發展出之問卷及採用其所確認的五項論病例計酬制度實施下所遇到之困難,包括「醫師不熟悉有關論病例計酬制度的規定」、「無法確認醫療品質」、「醫師感受到來自醫院的財務壓力」、「對醫師自主權的威脅」及「沒有適當的反應出疾病嚴重度」。本研究採用無記名方式對500位醫院內的醫師進行問卷調查,統計方法則採用複迴歸分析來探討醫師之特性與在實施論病例計酬制度下其所遭遇困難間之關係。 結果:經過複迥歸分析後,發現醫師在全民健保下的臨床年資(p=0.0016)、醫院的病床數(p=0.0436)、和立醫院(p=0.0046)與「醫師不熟悉有關論病例計酬制度的規定」有顯著關係。醫院的病床數(p=0.0337)、女性醫師(p=0.0005)及和立醫院(p=0.041)與「醫師感受來自醫院的財務壓力」有顯著關係。 結論:在健保局欲擴大實施論病例計酬項目範圍之際,確認那些醫師容易在論病例計酬制度下遭遇困難是非常重要的議題。相信教育醫師是幫助醫師從以論量計酬為主過渡到以論病例酬為主支付制度的最好方法之一。
Background and purpose: The shift from a fee-for-service-based to a case- based imbursement system may have implications to cost containment and quality improvement. However, as the likelihood of wide adoption of case payment increases, so does the fear escalate. Numerous barriers for implementing a successful case payment system are associated with physicians' practice behavior. The purpose of this paper is to exploit the relationship between physician characteristics and potential barriers to implementation of a case payment system in Taiwan. Methods: In this study, a questionnaire, developed by Lin and Amidon, was used. This 22-item questionnaire, using the Likert scale, consists of five dimensions of barriers to the implementation of the case payment system: 1) perceived barriers to compliance, 2) perceived barriers to quality assurance, 3) perceived financial pressure, 4) perceived threats to physician's autonomy, and 5) inadequate allowance for patient severity. The survey was administered to 500 hospital-based physicians between June and July 2000. Multiple regression analysis was performed for each of the five specific barriers, using physician characteristics as exploratory variables. Results: The perceived barrier to compliance among physicians is significantly related to the number of post-resident practicing years under the National Health Insurance (p=0.0016), number of beds (p=0.0436), and proprietary hospital status (p=0.0046). The perceived financial pressure for physicians is significantly associated with the number of beds (p=0.0337), being a female physician (p=0.0005), and proprietary hospital status (p=0.041). Conclusions: Identifying physicians who are more likely to perceive bathers with the implementation of the case payment is crucial to the success for health policy changes. Educational intervention is one of the major strategies that can enhance and facilitate physicians' smoothed transition from a fee-for-service-based to case-based reimbursement system.
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