全民健保各層級醫療院所氣喘疾病管理模式之質性探討－以高屏分局為例

An Analysis Based on Qualitative for Asthma Disease Management Model in NHI

劉慧俐(Hui-Li Liu) ； 黃明賢(Ming-Shyan Huang) ； 王鴻昌(Hong-Chung Wang)

《醫務管理期刊》 7卷1期 (2006/03) Pp. 81-106

https://doi.org/10.6174/JHM2006.7(1).81

摘要

氣喘是現代社會中常見且普遍的慢性病之一，會反覆的發作，有可能自行緩解，不能者若接受適當的治療，通常是可恢復的，但若是病況嚴重又未及時治療者，就可能會對生命造成威脅。由於氣喘這種可以控制但無法根治的特性，所以當氣喘未獲得控制時，會限制病患的社會活動及造成氣喘病患生活及事業上的不便，嚴重時更造成病患心理、生理上的不適，使得病患的生活品質受到損害。
中央健康保險局於90年11月起實施五大疾病醫療改善方案，以「論質計酬」購買健康的概念取代以往購買醫療的觀念。其中為加強對氣喘病患之照護，中央健康保險局透過支付制度設計，導入提昇氣喘照護品質之誘因，並於90年11月開始施行「全民健康保險氣喘醫療給付改善方案試辦計畫」，計畫內容為鼓勵醫事服務機構建立疾病管理模式，導入支付制度設計誘因，促使醫師組成照護團隊，加強病人衛教及追蹤，並提供病人連續且完整的照護模式，以提昇氣喘患者之自我照護能力及照護品質。
本研究以健保局高屏分局轄下各層級醫療院所為研究對象，首先隨機抽取現階段參與氣喘疾管計畫之醫療院所，再協調病人數多且有合作意願者共九家進行研究。藉由參與觀察、深入訪談及焦點團體等多元質性研究方法，進行本研究。研究結果如下：
一、各層級醫療院所實施的成人氣喘疾病管理模式各有不同。
二、以DMAA的標準來檢視，台灣地區只能算是支援性的疾病管理，而非標準的疾病管理。
三、與國健局之氣喘診療指引作比較，不同層級醫療院所個案管理模式之缺口有所不同。
四、藉由各層級醫療院所的疾管經驗討論，研擬標準化的氣喘疾病管理模式。
研究結果期作為衛生行政單位未來規劃及改進氣喘疾病管理之參考。

關鍵字

氣喘 ； 疾病管理 ； 全民健保氣喘醫療給付改善方案 ； 焦點團體

並列摘要

Objectives: Disease management on asthma was an important issue of assisting patients to control their diseases continuously and effectively. The Bureau of National Health Insurance (BNHI) sets up the quality based payment system, a disease management system to improve payment of asthma, in order to raise the quality of taking care of these patients. The system has been practiced for three years. Therefore, it probably has made certain effect on different levels of hospitals management. This study including difficulties and the responding strategies taken by the study objects, so as to make up the deficiencies of previous quantitative studies, to truly reflect workers experiences, and try to dialogue with current policies ad systems, in order to offer some references to policy makers and service providers for further planning of asthma disease management.
Materials and Methods: The subjects of the study are different levels of hospitals having practiced the asthma disease management for one year. The multimethod includes participant observation, depth interview, and related materials from medical institutions to seeking trustworthiness.
Nine different levels of hospitals were randomly selected in the Kao-Ping Branch. The qualitative data regarding asthma disease manager's experiences were derived from the focus group.
Results: The BNHI set up the quality based payment system has been practiced for three years. There were four types of disease management in Taiwan. From the viewpoints of Disease Management Association of American applied in this study, there were incompletely setting-up a work team to manage asthma, less centering on patients with intervention of health education, insufficient follow-up assessments of asthma patients, and unclear definition of quality assessment indicator of the asthma disease management system. The results proposed to the authorities concerned and different levels of hospitals for reference in developing disease management of self- care with asthmatics program.
Conclusions: To Health Insurance, a well-designed disease management plan provides patients good care quality. To hospitals, executing the plan can manage the medical teams and provide patients better cares. It is a triple wins for patients, medical treatment, and insurance. Based on the research s results, we hope to help establish a Taiwanese asthma disease management model to provide guidelines for clinical practice and modify health policy design of Department of Health, and promote quality of health maintenance for asthma patients.

並列關鍵字

Asthma ； disease management ； The Trial for the Improvement Scheme of Medical Reimbursement for Asthma Care by BNHI ； Focus Group

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