中央健保局自九十三年七月一日起實施『九十三年度醫院卓越計畫支付原則』(簡稱「醫院卓越計畫」) 政策，對於健保給付總額中的門診和住院各訂有固定比例(45:55)之總體目標，由各家醫院擬具醫院卓越計畫書，向健保局各分局提出申請，希望對個別醫院進行總量管制以達到抑制醫療費用逐年上升的目的。
本研究係以個案醫院門診病患就醫情形為對象，探討醫療院所實施「醫院卓越計畫」 政策之影響因子介入前、中及取消後對醫療院所之門診就醫人次及各項醫療費用等醫療行為之變化情形，以估評健保卓越計劃對醫療院所營運所造成之影響。
本研究主要結果如下：
一、門診病患看診人次、醫療費用、檢查費用及藥費方面：
政策實施中期間，門診病患就診人次、醫療費用、檢查費用及藥費有明顯減少；政策取消後，醫療費用、檢查費用及藥費有明顯增加，但門診病患就診人次沒有明顯增加。
二、在醫師平均看診人次改變方面：
政策介入對於醫師門診看診之病患人次有下降，政策取消後醫師門診看診之病患人次仍呈現減少。
三、門診佔率改變方面：
政策實施前每月門診佔率為42.94%，於實施中每月門診佔率為40.39%，但政策取消後每月門診佔率些微上升為42.17%。
四、藥費佔率方面：
政策實施中每月門診藥費佔率減少約3%；政策取消後藥費微幅上升不到1%。
五、對各臨床部科門診之影響：
政策實施中各科之門診看診人次減少，但門診醫療費用包含檢查費及藥費沒有明顯減少。政策消失後各科之看診人次沒有回升，門診醫療費用包含檢查費及藥費也沒有明顯回升。
六、對急診之影響：
政策取消後比政策實施中之急診每週發生之醫療費用沒有明顯增加，但是急診病患每人次的醫療費用有明顯增加。
根據以上的結果，本研究提出的建議如下：
一、對醫療政策制定者的建議
政策制定時應審慎訂定符合就醫病患需求及醫療院所的特性之政策及管理指標，並避免朝令夕改，讓醫療院所能有所依循，以提供就醫病患穩定的醫療品質。
二、對醫院管理者的建議
針對醫療院所的使命與願景提供病患良好的醫療服務品質，並讓不同需求的病患接受適切的醫療照護。
三、對後續研究者的建議
其他醫療院所醫療行為之改變、醫療政策介入對門診病患醫療行為改變、醫師醫療行為特質對政策介入之影響等可列入後續研究之範圍。The Bureau of National Health Insurance officially put into enforcement the “Hospital Excellency Project Payment Principles, 2004”(“Hospital Excellency Project”) on July 1, 2004. Under the Plan, all hospitals should file applications to the Bureau of National Health Insurance with their respective Hospital Excellency Projects in writing at the fixed ratio between outpatient and inpatient services at (45:55). It is hoped that the medical treatment costs can be put under control from further rises year-by-year by means of total quantity control (total mass control) by hospitals themselves respectively.
The present study aims at the outpatients who called the case hospitals as the samples to probe into the variation curves of the numbers of patients, medical treatment costs and such medical behaviors before, during involvement of the factors in the “Hospital Excellency Project” enforcement, and after annulment of such enforcement. Through the findings so obtained, the study is to assess the influence of the Hospital Excellency Project upon hospitals and clinics upon their operations.
The major findings yielded in the present study are enumerated below:
I. In the aspects of number of outpatients, medical treatment costs, examination costs and pharmaceutical costs:
During enforcement of such Plan, number of outpatients, medical treatment costs, examination costs and pharmaceutical costs showed significant signs of decline. After the plan was annulled, the medical treatment costs, examination costs and pharmaceutical costs were found to have significant increase while the number of outpatients did not have a significant increase.
II. Variation of the number of outpatients attended by doctors/physicians:
The involvement of the Plan led to a drop in the number of outpatients attended by doctors/physicians. After the Plan was annulled, the number of outpatients attended by doctors/physicians still showed signs of decline.
III. Variation in the ratio taken by outpatient services:
The outpatient services accounted for 42.94% to the total every month prior to enforcement of the Plan. The ratio down to 40.39% every month during enforcement of the Plan and a slightly up to 42.17% after the Plan was terminated.
IV. Ratio of pharmaceutical expenses:
The ratio of pharmaceutical expenses decreased by approximately 3% every month during enforcement and rose insignificantly within less than 1% after the enforcement came to a halt.
V. The influence upon outpatient services of various clinical departments:
During enforcement of the Plan, the numbers of outpatients visiting various departments came down. The outpatient service expenses, including examination expenses and pharmaceutical expenses did not come down. After the Plan was suspended from enforcement, outpatient service expenses, including examination expenses and pharmaceutical expenses did not come up significantly.
VI. The influence upon the emergency cases:
The emergency treatment expenses incurred every week did not show a significant increase after the Plan was suspended from enforcement compared with the expenses incurred during enforcement. The per patient treatment costs, nevertheless, showed a significant rise.
Summing up the key findings quoted above, the present study would offer the following proposals:
I. Proposals posed toward the medical treatment policymakers:
Upon policymaking process, it is advisable to come to the politic and managerial targets which would accurately aim at patients’ demand and hospital characteristics. The policies, once made, should be enforced consistently as far as possible, with as little change as possible. In turn, the hospitals will get a firm rule to comply with and thus upgrade the quality of medical treatment.
II. Proposals posed toward hospital management:
Aiming at the respective hospital missions and visions, the hospitals should try their utmost efforts to offer the best possible quality of medical treatment. Meanwhile, they should try to have patients of varied demands receiving medical care as appropriate.
III. Proposals posed toward subsequent researchers:
Change in other medical treatment behaviors of hospitals, change in the behaviors of medical care toward outpatients, the characteristics of doctors/physicians toward the involvement of the policies and such issues are advisable issues for subsequent study in the future.摘要 ………………………………………………………………… i
目錄 ………………………………………………………………… v
表目錄……………………………………………………………… vii
圖目錄……………………………………………………………… ix
第一章 緒論………………………………………………………… 1
第一節 研究背景………………………………………………… 1
第二節 研究動機與目的………………………………………… 3
第二章 文獻探討…………………………………………………… 4
第一節 各國健康保險制度……………………………………… 4
第二節 醫療保險之道德危機度………………………………… 15
第三節 總額支付制……………………………………………… 17
第四節 台灣地區總額支付制度實施狀況……………………… 27
第五節 目前我國台灣地區支付制度實施現況………………… 35
第三章 研究方法…………………………………………………… 38
第一節 研究對象及範圍………………………………………… 38
第二節 研究架構………………………………………………… 38
第三節 研究設計與抽樣方法…………………………………… 40
第四節 研究假設………………………………………………… 41
第五節 資料蒐集………………………………………………… 42
第六節 資料分析………………………………………………… 43
第四章 研究結果…………………………………………………… 44
第一節 門診病患平均就診次數及費用分析…………………… 44
第二節 醫師平均看診人次分析………………………………… 60
第三節 門診佔率之分析………………………………………… 62
第四節 藥費佔率之分析………………………………………… 62
第五節 對各臨床部科影響之分析……………………………… 63
第六節 對急診影響之分析……………………………………… 66
第五章 研究討論…………………………………………………… 74
第一節 門診病患平均就診次數及費用之探討………………… 74
第二節 醫師平均看診人次改變之探討………………………… 79
第三節 門診佔率之探討………………………………………… 80
第四節 藥費佔率之探討………………………………………… 81
第五節 對各臨床部科影響之探討……………………………… 82
第六節 對急診影響之探討……………………………………… 83
第六章 結論與建議…----………---……………………………… 86
第一節 結論……………………………………………………… 86
第二節 研究限制………………………………………………… 92
第三節 建議……………………………………………………… 93
參考文獻 …………………………………………………………… 96
英文部分……………………………………………………………… 96
中文部份 …………………………………………………………… 97
附件………………………………………………………………… 9
