全民健保制度下醫院營運動向與經營效率之相關性探討

A Study on the Relationship between Hospital Operating Trend and Operating Efficiency under the National Health Insurance System

洪欣宜(Hsin-Yi Hung)

指導教授 ： 陳金淵

長榮大學/健康科學學院/醫務管理學系(所)/碩士(2012年)

https://doi.org/10.6833/CJCU.2012.00087

摘要

目的 國內於民國84年3月實施全民健康保險，醫療支付方式不斷變革，由初始之論量計酬至現今的總額支付制度實施，目的乃為彌補健保財務缺口，然而醫療院所在資源有限與競爭激烈的醫療環境下，已由過往之榮景到今產生「適者生存，不適者淘汰」現象。國內醫院家數由民國83年之719家到民國96年餘507家，診所家數卻由14,924家增長至19,370家，不禁令人思索落差212家醫院是何因素所致及其何去何從？加上實證研究結果顯示，企業發生危機時其經營效率確有惡化趨勢，且為市場競爭過程中遭淘汰的主因，而生產效率的衡量可知資源耗用情形，故而引發本研究想窺探在醫療產業中其醫院營運動向與其經營效率之相關性。
方法 本研究以衛生署所提供民國83年至96年「醫療機構現況」及「醫療服務量統計」之次級資料做分析。選取醫院、綜合醫院合計710家醫院為研究對象，並以病床數、醫師人員數、護理人員數、醫技人員數、住院人次、手術人次、門急診人次為投入與產出項，運用資料包絡分析法的CCR模式與BCC模式，以Frontier Analyst Professional Version3.2.2版軟體計算研究對象之逐年效率值，再依醫院之營運動向、權屬別、區域別、評鑑等級分類，以SPSS12.0統計軟體進行資料描述、Pearson 相關性、卡方檢定、t檢定、One-way和Two-way ANOVA檢定，以瞭解營運醫院與異動醫院之效率變化及其差異性。
結果 當營運動向有所改變時，整體樣本醫院以歇業型態占居多（約52%），其次為轉型成診所（42%）；公立醫院以合併經營方式居多（約43%），私立醫院以歇業型態居多（約54%）。若僅就異動醫院之純技術效率表現而言，可發現整體異動醫院在異動前二年、前三年效率表現較好。依異動型態分類，歇業醫院在異動前一年效率表現較好，轉型診所之醫院在異動前二年、前三年效率表現較好；依權屬別分類，公立醫院、私立醫院不論年期為幾年皆無明顯差異；依區域分類，台北區域之醫院在異動前四年效率表現較好，其餘區域則無差異。
結論 藉由資料包絡分析法可獲知醫院之營運動向與效率表現之相關性為何。本研究發現開業醫院以規模效率表現較高，異動醫院以純技術效率現較高；另外，異動醫院在異動前二年、前三年之純技術效率表現較好。反映出在資源有限、慾望無窮與競爭激烈的醫療環境中，面對不斷變革之健保支付制度，經營者除了要以較少投入達到產出極大化，更要讓醫院處在最適經濟規模生產，以使醫院能在詭譎多變之醫療環境中求生存。此外，「資源重分配」已是當今衛生主管機關主要思量點之一，建議其在推行相關政策時，宜有配套措施或誘因，讓制定者與執行者能共謀其利並不損民眾福利與權利，以達到三贏境界。

關鍵字

全民健保制度 ； 營運動向 ； 經營效率

並列摘要

Objectives Since the National Health Insurance program took effect in March, 1995, the methods of medical payments have changed dramatically. To bridge the gap of health insurance finances, the methods have been changed from fee-for-service at first to global budgeting now. However, due to the limited resources and the extremely competitive environment, the phenomenon of “survival of the fittest” has replaced the past prosperity of the hospitals. The number of hospitals nationwide has reduced from 719 in 1994 to 507 in 2007, but the number of clinics has increased from 14,924 to 19,370 during the same time frame. We can not help pondering what caused the reduction of the 212 hospitals and what came of them. Moreover, empirical research has shown that operating efficiency deteriorates when an enterprise is in crisis, and it is also the main cause of elimination during periods of increased market competition. Therefore, this study was aimed to examine the relationship between operating trends and operating efficiency in the domestic hospital industry.
Methods Analyses were based on secondary data derived from the “Profiling of Hospitals” and “Statistics of Medical Service” between 1994 and 2007, offered by the Department of Health. 710 hospitals and general hospitals were the objects of this study. The numbers of beds, physicians, nurses, medical technicians, inpatients, surgical patients, outpatients, and emergency cases were used as the input and output variables. The CCR and BCC models of data envelopment analysis（DEA）were implemented and Frontier Analyst was used to compute the yearly efficiency scores for each decision making unit (DMU), classified by hospital operating trend, ownership, geographical areas, and levels of accreditation. The statistical software SPSS12.0 was used to conduct data analyses, including Pearson correlation, Chi-square test, t test, One-way and Two-way ANOVA tests in order to understand the changes and differences of operating efficiency of the hospitals and the hospital operating trends.
Results The majority of changes in operating trends were hospital closure (about 52%); approximately 42% transformed into clinics; most of the public hospitals chose to merge with other hospitals (about 43%), and most private hospitals chose to cease operations (about 54%). When considering only the pure technical efficiency of changing hospitals, we found that overall the changing hospitals performed better in the second and third years before the changes. Further, closed hospitals performed better in the year before, and hospitals transforming into clinics performed better in the second and third years before the changes. No significant differences were found between public and private hospitals, regardless of years in operation. Hospitals in Taipei region performed better in the fourth year before the changes. No difference was found in other regions.
Conclusions The relationship between hospital operating trend and operating efficiency can be examined through data envelopment analysis. This study found that operating hospitals had higher scale efficiency, and closed hospitals had higher pure technical efficiency. The pure technical efficiency of changing hospitals was better in the second and third years before the changes, indicating that in an environment with limited resources, fierce competition, and continually changing health insurance payment systems, management needs to maximize the operating efficiency and also to keep the hospitals operating on optimal economics of scale so that the hospitals can survive. Furthermore, the “reallocation of resources” has become one of the main issues for the Department of Health. It is suggested that when enforcing related policies, the government should have supplementary measures or stimulants so that law-makers and law executors can gain benefits without impairing public welfare and rights to achieve a three-win situation.

並列關鍵字

National Health Insurance ； operating trend ； operating efficiency

參考文獻

財團法人醫院評鑑暨醫療品質策進會（2009）。取自http://wwww.tjcha.org.tw/NewsDetail.asp?NewsId=539

黃月桂、張保隆、李延春（1996）。台北市立綜合醫院經營績效之評估。中華衛誌，15（4），382-390。

謝琇蓮、江東亮（1994），臺灣地區醫院歇業及新設之決定因素，中華衛誌，13（6），453-457。

馬作鏹、洪思雯、邱晏麟（2004）。市場定位與經營競爭度對地區醫院歇業之影響。中台灣醫誌，9 Suppl 1，16-26。

陳巧珊、程于珊、許怡欣（2008）。運用資料包絡分析法探討署立醫院、縣市立醫院及其他委託經營醫院經營效率。澄清醫護管理雜誌，4（3），7-13。