臺灣博碩士論文加值系統

摘 要
目的：全民健保實施至今，健保局為確保醫療品質，降低醫療成本，及不影響民眾就醫的權益下，提出了自主管理方案，本研究希望了解醫院是、否加入自主管理對醫院成本控制與相關管理策略及顧客導向的因應情形，以探討醫院總額支付制度下，醫院自主管理對於醫院管理的影響。
方法：本研究之對象為醫院評鑑合格之教學醫院，以結構式問卷對樣本醫院進行調查，回收有效問卷60份。本研究除了以描述性統計分析與雙變項分析探討醫院自主管理各項因應策略的意向程度，同時以複迴歸分析，探討醫院自主管理對於醫院相關管理策略之影響，以及其他影響醫院管理策略之因素。
結果：在總額預算制度下，超過一半以上的醫院有參與自主管理之經驗。目前加入自主管理醫院相對於從未加入自主管理醫院在「加強財務及成本管理」策略意向上是較高的。目前加入自主管理醫院相對於從未加入自主管理醫院「顧客導向」策略上有較高的意向。醫學中心和區域醫院相對於地區教學醫院在「增加收入策略」方面意向是較高的。私人醫院相對於公立醫院在「增加收入策略」方面是有顯著的。有設立分院之醫院相對於無設立分院之醫院在「合作性策略」方面有顯著的負相關。在31項策略中最被認同的是「成本意識的建立及內化」，最不被認同採用的是「避免疾病較嚴重者」策略。
結論與建議：整體來說醫院加入自主管理後，醫院在民眾醫療品質及醫院成本控制提昇方面是有較高的意向。因此本研究建議：(1) 醫院在控制成本下應考量對病患權益的影響。(2)醫院應更加強醫療品質相關策略重視程度。(3)對衛生主管機關則建議應留意自主管理對台灣醫療技術水準之發展及醫療生態的改變。

關鍵詞：醫院自主管理、總額預算、管理策略

Abstract
Objectives: To ensure the medical quality, cope with the financial shortfalls, and maintain comprehensive medical benefits to the public, the Bureau of National Health Insurance implemented the hospital-based budget payment (HBBP) program. The purpose of this research is to examine whether joining the HBBP program will affect a hospital’s cost control, customer service, and relative operating strategies. This study further explores the impact of the HBBP program, under the global budget reimbursement system, on the management strategies of participating hospitals.

Method: Using all accredited teaching hospital as a target, sixty hospitals responded to our structural questionnaire. In addition to applying descriptive statistics and multi variable analyses to measure the degrees of intentions for all adjustment strategies regarding the HBBP program, this study employs multiple regressions to explore the influence of HBBP and other related factors on managerial strategies.

Results: Under the global budget reimbursement system, there are more than half of the sample hospitals which have had the experiences of participating in the HBBP program. HBBP- participating hospitals have higher strategic intentions on strengthening financial and cost managements and customer-oriented strategy than those which never enroll in the HBBP program. Relative to local community teaching hospitals, academic medical centers and metropolitan hospitals have higher degrees of intentions for revenue-increasing strategies. Compared with private hospitals, public hospitals also show a higher degree of intention toward revenue-increasing strategies. There exists a negative relationship on the cooperative strategy between sample hospitals with branches and those without branches. Among thirty-one surveyed strategies, the strategy of establishing and internalizing cost consciousness earns the highest consensus, while the strategy of avoiding the catastrophic illness has the lowest consensus.
Conclusions: Overall, this study finds that after joining the HBBP program, the sample hospitals had a higher intention to enhance medical quality to the public and increase cost controls. Therefore, we suggest that: (1) While pursuing cost controls, hospitals should take patients’ rights and benefits into considerations. (2) Hospitals need to pay more attention to the related strategies of improving medical quality. (3) Health service authorities need to observe the effect of the HBBP program on the development of Taiwan medical processes and the allocation of medical resources.

Keywords: Hospital-Based Self-Management, Hospital-Based Global Budget, Strategic Management

目 錄

第一章 緒論
第一節 研究背景---------------------------------01
第二節 研究目的---------------------------------04
第二章　文獻探討--------------------------------05
第一節 全民健保支付制度--------------------------05
第二節 醫院自主管理之沿革-------------------08
第三節 加拿大之全民健保--------------------------12
第四節 支付制度對醫療服務型態之影響---------------14
第五節 近年來台灣醫療生態之變化-------------------19
第六節 醫療院所因應總額預算的可能方式--------------26
第七節 文獻探討總結------------------------------32
第三章　研究設計與研究方法------------------------33
第一節 研究流程與研究架構-------------------------33
第二節 資料來源與資料分析--------------------35
第三節 變項操作型定義----------------------------37
第四節 統計分析方法服務型態之影響------------------39


第四章 研究結果--------------------------------42
第一節 描述性統計分析----------------------------42
第二節 推論性統計分析分析--------------------45
第五章 討論------------------------------------51
第一節 醫院總額制度下醫院管理策略認同差異探討--------51
第二節 運用改變服務量策略之差異探討------------53
第三節 加強財務成本管理策略之差異探討---------------56
第四節 增加收入策略之差異探討-----------------59
第五節 合作性策略之差異探討------------------------61
第六節 顧客導向策略之差異探討-----------------63
第六章 結論(與建議)-----------------------------64
第一節 結論--------------------------------------64
第二節 建議---------------------------------66
第三節 研究限制-----------------------------------67

參考文獻-----------------------------------------78

附錄一 「調查醫院自主管理的相關因應管理策」問卷------84
附錄二 問卷效度之專家名單------------------------86


表圖目錄
表2-1　醫院卓越計劃與自主管理之比較--------------------9
表2-2 台灣地區醫院與診所家數------------------------20
表2-3　歷年來醫院歇業及新設情形-----------------------22
表3-1　醫院特質變項名稱及操作型定義-------------------37
表3-2 醫院對自主管理策略之意願變項名稱及操作型定義-----38
表4-1　樣本醫院基本特性之描述性分析-------------------68
表4-2 各項策略同意程度分數之描述性分析---------------69
表4-3 參與自主管理情形與樣本醫院基本特性卡方分析表-----70
表4-4 各項策略同意程度分數比較—依自主管理狀態區分表---71
表4-5 各項策略同意程度分數比較—依醫院層級區分---------72
表4-6 各項策略同意程度分數比較—依醫院屬性區分---------73
表4-7 各項策略同意程度分數比較—依是否有分院區---------74
表4-8 各項策略同意程度分數比較—依是否有聯盟醫院區分---75
表4-9　皮爾森相關分析-----------------------------------76
表4-10 各因應管理策略之複迴歸分析-----------------------77

圖2-1　台灣地區醫院與診所家數趨勢圖------------------22
圖2-2　歷年來醫院歇業及新設趨勢----------------------23

圖2-3　歷年來醫院與診所醫師數------------------------23
圖2-4　歷年不同層級醫院家數--------------------------24
圖2-5　歷年不同層級醫院病床數------------------------25
圖3-1　本研究流程------------------------------------33
圖3-2　本研究之研究架構------------------------------34

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