過去已有許多研究探討市場競爭與廠商行為的議題，但多半著重於市場競爭和醫院成本的關係，甚少探討市場競爭的測量以及市場競爭對於醫療品質的影響。本研究分為下列三個主題：(1)主題一：競爭程度的測量：以台灣的醫療照護市場為例；(2)主題二：檢驗醫院市場競爭程度分別與病患主觀感受品質及傳統客觀品質指標之相關性；(3)主題三：檢驗醫院市場競爭與病患主觀感受品質的相關，是否透過醫院投入之中介機制所影響。資料來源方面，主題一：使用衛生署統計室1994年至2007年「醫院服務量檔」；主題二、三：使用2002年及2004年「出院病人調查」資料串連當次住院的健保申報資料。針對不同主題採用不同的分析方式：主題一：描述各學派市場競爭程度，並檢驗歷年間各學派市場競爭程度之變化趨勢的相關性；主題二：採用工具性變項及隨機截距模型，檢驗市場競爭分別與病患主觀感受品質以及傳統客觀品質的相關性；主題三：採用階層式模型和隨機截距模型，檢驗醫院投入是否為市場競爭和病患主觀感受品質之中介因素。研究結果方面；主題一：發現不論是採用「結構學派」或「行為學派」之市場競爭程度，皆隨著年代呈現逐年下降的趨勢，且歷年不同學派間市場競爭指標具有中高度的相關性。主題二：發現醫院位於市場競爭程度愈高的地區，醫院病患不論在人際面或技術面所感受到的主觀醫療品質皆較高。然而，醫院面對的市場競爭程度與傳統客觀品質指標(病患出院後30日內的再住院情形)並無顯著相關。主題三：發現市場競爭對於人際面和技術面病患主觀感受品質有不同的影響機制：市場競爭對於病患人際面感受品質具有直接的影響力，換言之市場上存在品質競爭的情形；然而，控制護理人力素質後，醫院面對的市場競爭和病患技術面感受品質的關係減弱。研究之結論為：一、若醫院位於愈競爭的區域，出院病患感受品質愈高。二、醫院投入（護理人力素質）為市場競爭和病患技術面感受品質之中介機制。建議政府在制定醫療產業相關政策上，應該要引入市場競爭機制，且醫院評鑑制度應要規範醫院人力之素質。The majority of previous studies on the relationship between market competition and hospital behaviors have focused on the impact of competition on costs. However, the measures of market competition and it effects on health care quality have been rarely discussed. This study comprised three research topics: (1) Measuring market competition using data from Taiwan’s health care market; (2) Examining the relationship between hospital market competition and patient quality of care; and (3) Investigating the mediating effect of hospital input on the relationship between market competition and patient perceived quality of care.ata for the first research topic came from the “Health care institution survey” and “Hospital services volume survey” from 1994 to 2007. We compared the trend of market competition defined by the Structuralism with that by the Behaviorism. For the second and third research topics, we used the 2002 and 2004 “Discharge patient survey” and national health insurance claim datasets. Instrumental variable and random intercept model were applied to examining the impact of market competition on subjective and traditional objective quality of care measures. Furthermore, hierarchical models and random intercept model were performed to test the mediating effect of hospital input on the association between market competition and patient perceived quality of care. he level of market competition, measured either by Structuralism or Behaviorism, both showed to be decreasing. There was a significant and moderate correlation between the two measures. When hospitals were in a more competitive market, their patients reported better perceived quality of care in terms of interpersonal skills and clinical competence. However, competition level was not significantly associated with traditional quality indicator, the readmission rate after 30 days of discharge. The mechanism linking market competition and quality of interpersonal skills tended to be different from that linking competition and clinical competence. There was a direct effect of market competition on quality of interpersonal skills, while hospital input in nursing professional (skill mix) mediated the association between competition and quality of clinical competence. more competitive market is associated with better patient perceived quality. Hospital input (e.g. nursing professionalism) mediates the relationship between market competition and patient perceived quality of clinical competence. According to our findings, we suggest that the government should employ competition approach to promote the quality of hospital care and incorporate the quality of hospital staff in the hospital accreditation system.誌謝 I要 I文摘要 II一章 緒論 1一節 研究背景與動機 1二節 研究目的 4三節 研究重要性 5二章 文獻探討 7一節 市場競爭概念的理論 7二節 市場競爭和醫療品質的理論 12三節 市場競爭和醫療品質實證研究的回顧 21四節 市場競爭和醫療品質實證研究中方法學之討論 33五節 市場競爭和醫療品質之中介機制 47三章 研究方法 54一節 市場競爭程度的測量：以台灣醫療市場的競爭為例 55二節 市場競爭對病患主觀感受品質和傳統客觀品質的影響 63三節 市場競爭、醫院投入與病患主觀感受品質 73四章 研究結果 80一節 市場競爭程度的測量：以台灣醫療市場的競爭為例 80二節 市場競爭對病患主觀感受品質和傳統客觀品質的影響 95三節 市場競爭、醫院投入與病患主觀感受品質 120五章 討論 131一節 市場競爭程度的測量：以台灣醫療市場的競爭為例 131二節 市場競爭對病患主觀感受品質和傳統客觀品質的影響 135三節 市場競爭、醫院投入與病患主觀感受品質 141六章 結論與建議 145一節 研究結論 145二節 政策意涵 146三節 未來研究方向 147考文獻 148文文獻 148文文獻 14
