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研究生:熊心如
研究生(外文):Hsin-Ju Hsiung
論文名稱:全民健保總額支付制度與醫病關係之影響──某醫學中心之個案研究
論文名稱(外文):The Infulence of Global-budget-payment-system and doctor-patient Relationship : A Case study
指導教授:林財丁林財丁引用關係
指導教授(外文):Tsai-Din Lin
學位類別:碩士
校院名稱:東海大學
系所名稱:管理碩士學程在職進修專班
學門:商業及管理學門
學類:其他商業及管理學類
論文種類:學術論文
論文出版年:2005
畢業學年度:94
語文別:中文
論文頁數:113
中文關鍵詞:醫病關係總額支付制度論量計酬醫療提供者被保險人
外文關鍵詞:doctor-patient relationshipglobal budget payment systemfee-for-servicemedical providersthe insured
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摘 要

過去病人心目中認為只要能夠把病治好的醫生,大概也就是良醫了,但是,隨著科技的進步、網路資訊的發達、消費意識的抬頭、醫師與病人社會地位的改變,且國民知識水準提高等,傳統的病人對醫生崇拜服從的心態及和諧的醫病關係已經受到明顯的衝擊。

又84年全民健保的實施,由於健保初期沿用公勞保時期的論量計酬制度,引導醫療機構重「量」不重「質」的醫療行為,因而導致健保財務瀕臨破產。自87年推行的牙醫總額支付制度至91年的西醫醫院總額支付制度的施行,乃是為了減輕健保財務負擔,控制醫療支出成長,藉由醫療提供者共同承擔健保財務風險責任;因此,支付制度介入了醫病關係也引導醫院的管理作法,更因此影響了醫生看病行為。

本研究設計有關全民健保總額支付制度與醫學中心醫病關係研究之開放性問卷及量性問卷,分別訪談某醫學中心第一線的臨床醫護人員,研究結果發現如下。

1、 受訪者認為總額支付制度的實施影響醫生的看病行為及醫病關係。
2、 受訪者認為實施總額支付制度引起民眾與醫院的紛爭時,健保局卻置身度外。
3、 受訪者認為健保局沒有對民眾做好總額支付制度的宣導。
4、 受訪者認為醫病關係如何並不影響醫生的看病行為。
5、 良好的醫病關係是醫病雙方共同的責任,病人要能夠信任與尊重醫護人員及充分的配合治療計畫,醫病雙方才能獲得雙贏。
6、 唯有正確就醫習性,才能節省醫療資源的過度使用。
7、 醫病關係和諧的氣氛下,病人對醫護人員充滿信心及安全感,也願意配合醫療處置,而醫護人員可以獲得正確的診斷,因而,病人的疾病容易治癒。
8、 醫病關係和諧,可以提高醫護人員的工作情緒及增加成就感,因而其醫護專業可以盡情的發揮。
9、受訪者認為挽救健保財務的責任必需是健保局、醫療機構,及被保險人三者共同承擔。
10、重新思考健保的宗旨及精神,讓社會保險回歸其最基本的醫療照顧。
關鍵字:醫病關係、總額支付制度、論量計酬、醫療提供者、被保險人
The Influence of NHI`s Global-budget-payment-system and
Doctor-patient Relationship : A Case Study

ABSTRACT

Patients often thought that a good doctor is a doctor who can cure the sickness. However, the traditional obedient attitude of patients toward their doctors and the harmonious relationship between doctors and patients has been strongly challenged due to the progress of science and technology, the abundance of network information, the development of consumer conscious, the change of social status for both doctors and patients, and the increase of citizen knowledge, etc.

The implementation of the National Health Insurance (hereafter NHI) in 1995 is also an essential factor that causes the change of doctor-patient relationship. The Bureau of National Health Insurance (hereafter BNHI), at the beginning, continued using the same system as the Public Employee Insurance and the Labor Insurance in which the insurance pays by fee-for-service. This system consequently led the medical institutions to think highly of quantity rather than quality, and which has almost crashed the NHI. Therefore, for reducing the financial deficit, controlling the increase of medical expenses, and sharing the financial risk with the medical providers, the BNHI brought into practice the dental global budget payment system in 1998 and the global budget payment system for the western medicine clinics in 2002. The new payment system has intervened the doctor-patient relationship, led the medical institutions to change their way of management, and affected further the doctors’ behavior toward patients.
In this research, we designed a structure interview and a Likert-scale questionnaire to investigate the influence of the global budget payment system of NHI on the relationship between doctors and patients. All subjects were front-line doctors and nurses working at a medical center. The main results can be summarized as follows:
1. The respondents considered the global budget payment system influenced the relationship between doctors and patients.
2. When there were disputes and misunderstandings between patients and doctors caused by the global budget payment system, the BNHI was perceived to shun away from the disputes.
3. The respondents considered BNHI did not sufficiently make the global budget payment system known to the public.
4. According to the respondents, the doctor-patient relationship did not affect doctor’s treatment plan.
5. A successful doctor-patient relationship relies on doctors and patients. Only when patients trust and respect the professionals and the treatment program will there be a great benefit to both patients and doctors.
6. The payment system of health insurance is a principal factor that influences the manner and the measures of hospital administration. It also exerts a significant impact on the development of the doctor-patient relationship.
7. A good doctor-patient relationship is important in improving the cure rate. For patients, in a harmonious atmosphere, they feel secure to completely rely on doctors and nurses, and are willing to cooperate with medical treatment; for doctors and nurses, they can give patients the accurate diagnosis.
8. A harmonious doctor-patient relationship is of great help for the doctors and nurses to prompt working spirits and to build a stronger sense of achievements.
9. The BNHI, the medical institutions and the insured, they all should be responsible for saving the financial burden of NHI.
10. The objective and the spirit of the NHI should be reconsidered in order to respect and uphold the fundamental principle of social insurance, that is, the medical care.

keywords: doctor-patient relationship, global budget payment system, fee-for-service ,
medical providers, the insured.
目 錄

第一章 緒論…………………………………………………………P1-P10
第二章 文獻探討……………………………………………………P11-P16
第三章 研究方法與研究流程………………………………………P17-P18
第四章 研究結果與討論……………………………………………P19-P69
第五章 結論與建議…………………………………………………P70-P73
參考文獻…………………………………………………………… P74-P75
附錄一 開放性問卷 ……………………………………………… P76
附錄二 量性問卷……………………………………………………P77
附錄三 研究邀請函…………………………………………………P78
附錄四 訪談同意書…………………………………………………P79
附錄五 訪談記錄……………………………………………………P80
附錄六 醫病關係不和諧案例整理…………………………………P107
參考文獻

行政院衛生署(2004)。全民健保改革宗論。10月31日

行政院衛生署(2004)。全民健保與醫療品質。10月31日

李玉春(1996)。健康保險支付制度。於楊志良主編,健康保險(68-113頁)。台北:巨流。
莊逸洲、黃崇哲合著(2000)。醫療機構人力資源管理。華杏出版股份有限公司。

張文凱(2003)。運用危機管理建構醫療糾紛預防之模式─以醫院住院為例。國立雲林科技大學工業工程研究所碩士論文。

陳楚杰(1999)。醫院組織與管理。台北:宏瀚文化事業有限公司。

楊志良(2000)。健康保險。台北:巨流圖書公司。

潘憶文等(2001)。醫院組織功能與管理。台北:偉華書局有限公司。

蕭文(1991)。健康保險。台北:南山堂出版社。

顏裕庭(1995)。全民健保理念與展望。台北:藝軒圖書出版社。

羅紀瓊(1996)。健康保險財務制度。於楊志良主編,健康保險(40-65頁)。台北:巨流
中央健康保險局全球資訊網。http://www.nhi.gov.tw

張朝凱(2001)。淺談全民健保總額預算制度。
http://www.lasikeyd.com.tw/nanazine/200106.htm

楊志良(2005)。全民健康保險的問題與改革。http://www.npf.org.tw/PUBLICATION/SS/094/SS-B-094-013.htm。5月

蔡甫昌(2002)。醫病關係與執業倫理。
http://210.60.194.100/life2000/ethic_discuss/ethic_dis_65/BOARD.HTM

賴其萬(2003)。也談台灣的醫病關係。http://health.bookzone.com.tw/lin-tital.asp?no=250&hser=16。12月31日

聯合新聞網。http://yam.udn.com/yamnews/daily/2248554.shtml
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