全民健保下私立小型醫院困境與策略- 發展以醫院為基礎的護理之家可行性研究

The Difficulties and Strategies of Private District Hospitals under National Health Insurance System—the Feasibility of Developing Hospital-Based Nursing Homes

余政經(Cheng-Ching Yu)

指導教授 ： 薛亞聖

國立臺灣大學/公共衛生學院/醫療機構管理研究所/碩士(2006年)

https://doi.org/10.6342/NTU.2006.00818

摘要

研究目的
本研究之研究目的為了解1、地區醫院之特性；2、地區醫院目前面臨之經營困境；3、地區醫院發展長期照護之可行性；4、地區醫院開設護理之家的SWOT分析5、地區醫院開設護理之家的關鍵因素。
研究方法
本研究除採用文獻資料分析，並以三位地區醫院實際經營者為受訪者，於民國九十四年採用質性研究之深度訪談法了解經營者在目前經營地區醫院上所碰到的困境，與開設護理之家是否能成為解決困境的因應方式；再輔以二位前政府衛生官員的訪談資料，以多角度的觀點來看待地區醫院困境與開設護理之家的議題。
重要研究發現與結論
小型醫院面臨的主要困境：人員聘請不易、住院收入減少、競爭優勢不足、健保給付緊縮、評鑑標準嚴格。地區醫院主要因應方式：策略聯盟、委託經營、開設護理之家、聯合門診、聯合採購。地區醫院設立護理之家SWOT分析：1.優勢（S）：硬體設備較佳、緊急照護品質佳、人力調配靈活自由、醫療資源豐富、照護人員專業；2.劣勢（W）：醫療糾紛較多、醫院氣氛不好、照護人員流動率高、收費較高；3.機會（O）：亞急性照護需求增加、老人慢性病醫療增加、老化需求、社會需要；4.威脅（T）：價格競爭大、品質要求提昇。
建議
政策與管理方面：1.建議政府建立亞急性照護制度、輔導小型醫院發展以醫院為基礎的護理之家，使之成為亞急性照護機構，強化長期照護概念，修訂醫院最少急性病床數由二十床減為十床；2.建議健保局對於亞急性照護予以給付；3.建議提昇地區醫院管理品質，收住大型醫院與獨立型護理之家之亞急性住民。未來研究方面：1.可增加北部或其它地區的小型醫院、大型醫院、獨立型護理之家的訪談，以了解南北是否有文化差異以及各層級間的參與與互動；2.調查潛在的亞急性病人數，以為輔導地區醫院發展亞急性照護機構之參考。

關鍵字

地區醫院 ； 亞急性照護 ； 護理之家 ； 長期照護 ； SWOT分析 ； 健康保險 ； 策略

並列摘要

Objective
The objectives of this study are to understand: (1) the characteristics of the district hospitals; (2) the management problems that district hospitals are facing currently; (3) the feasibility of developing hospital-based nursing home (4) the SWOT analysis of hospital-based nursing home (5) the key factors that have helped district hospitals transformed into nursing homes.

Method
This study has adopted in-depth interview of qualitative research in 2005 on three individuals who were CEO of district hospitals to discuss the management problems that the district hospitals are facing currently and whether the establishment of nursing home can be the solution. Subsequently, interview with two former health officers are supplemented to address the dilemma faced by district hospitals and broader viewpoints on the establishment of nursing home.

Significant findings & conclusion
The major dilemma faced by district hospitals: the difficulties of recruitment, the decreasing source of income from inpatients, the inadequacy of competitive advantages, the tightening of health insurance subsidy and the rigidity of evaluation standard. The strategies of district hospitals: the strategic alliance, the joint venture, the hospital-based nursing home, the joint outpatient service and collective purchase. The SWOT analysis for hospital- based nursing home: (1) Strengths (S) – the better hardware equipments, the outstanding emergent nursing quality, the flexible human resource allocation, the abundant medical resources and the professional nursing staff; (2) Weaknesses (W) – more medical disputes, worse atmosphere in hospitals, high turnover rate of nursing staff and higher charges; (3) Opportunities (O) – the increasing needs for sub-acute care, the rising medical treatment of chronic illness for elderly, the ageing needs and the social needs; (4) Threats (T) – keen competition in prices and demand for improving quality.

Suggestions
Policy and management: (1) The government should establish sub-acute care system and assist small-scaled hospitals to develop hospital-based nursing home, converting them into sub-acute care institutions, as well as consolidating their concepts of long-term care and reduce the minimum number of bed for acute illness from 20 to 10. (2) The Bureau of National Health Insurance should subsidize sub-acute care. (3) The district hospitals should improve their management quality to ward sub-acute residents from large-scaled hospitals to independent nursing home. Future study: (1) Conduct more interviews in district hospitals, large scale hospitals and independent nursing homes in the Northern cities or other cities in Taiwan to get a better understanding of whether there are cultural differences between the Northern cities and Southern cities, as well as participation and interaction among all levels of health care organizations; (2) investigate the number of potential sub-acute patients and using the results as references for assisting district hospitals to develop sub-acute care institution.

並列關鍵字

district hospital ； sub-acute care ； nursing home ； long-term care ； SWOT analysis ； health insurance ； strategy

參考文獻

6.張彩秀（1997）•中部某區域醫院慢性病病人選擇長期照護方式之評估研究•弘光學報，30，1-12。

80.吳淑瓊、徐慧娟、莊瑛智、張明正（1996）•功能評估在估計台灣社區老人長期照護需要之應用•中華衛誌，15（6），533-545。

4.謝琇蓮、江東亮（1994）•台灣地區醫院歇業及新設之決定因素•中華民國公共衛生雜誌，13（6），453-457。

31.張錫惠、傅鐘仁（1998）•我國醫療服務品質滿意度之研究•主計月報，85（6），51-60。

10.邱文達、朱子斌、陳欽賢、劉彩卿（2001）•兩岸醫療保險制度變革的比較與剖析•醫務管理期刊，2（3），1-26。