臺灣博碩士論文加值系統

自從民國八十四年三月全民健康保險制度開辦以來，提供了全世界最佳的病患醫療可近性，高度自由的就醫選擇權，以及高品質的醫療服務。但也造成醫院費用支出持續上升，健保局為因應財務狀況，陸續推行許多財務緊縮政策，造成醫療產業環境的不確定性與複雜性。尤其實施醫院總額支付制度迄今，在全球經濟成長衰退不景氣，國內人口老化、失業人口增加，醫療資源日益不足及健保財務吃緊下，中央健康保險局由支付制度面進行成本控制，逐步調整給付標準，朝單一給付標準化，故自99年1月起逐年分階段改革給付醫療院所方式為TW-DRGSs「住院診斷關聯群」支付制度。
新制上路後，未來只要是醫療資源比較相近的部分就會歸類成同一類，依疾病種類、手術與年齡、性別、有無合併症等條件分類，按照病況輕重等級分組，定額給付，如果低於下限，會採核實申報方式，也就是「同嚴重度同酬」給付制度。政府實施「TW-DRGSs」之政策目的，除了為提升醫療服務效率，減少浪費，亦可改善病患照護品質與療效，是讓醫院成本最佳化，但DRG的實施也會造成醫院相當的衝擊，可能加重醫療機構的照護與財務責任及風險。
但是醫院的屬性（例如設立目標、角色定位、組織及權責結構等）不同，醫院面臨健保支付制度改變之財務壓力以及因應方式也會有所不同，國軍醫院除了肩負國家照顧軍人健康的政策責任，更重視經營績效。因此因應健保支付制度改變所採取降低成本之措施及效率也將有所不同，而這些差異也將反應在其醫療服務量、收入及利益等財務績效指標之表現上。如何增進醫院的財務績效、同時兼顧醫院經營目標、醫療服務品質及病患滿意，將為醫院永續經營的關鍵因素。
在「住院診斷關聯群」首重病例臨床路徑標準化，而影響臨床路徑標準化制定則首當住院天數，故本研究所建構之系統動力學模型，選擇第一階段實施TW-DRGSs 155項之住院天數、醫院TW-DRGSs案件數、佔床率及住院滿意度等，這些相互影響關係值的模擬均採用Table function 進行模擬。而本研究所提出的Table function 是透過個案醫院在平日常營運過程中的真實數據、觀察、經驗判斷或是相關文獻參考所得之資料，其績效衡量指標系統僅能代表國軍醫院個案，而無法證明其他規模醫院之適切性為何；且本研究僅依照個案醫院系統模式進行模擬，當系統模式不同時可能出現不同之結果。
期望透過本研究能給個案醫院在管理、經營與臨床路徑制定方面一些建議，在維護病患整體權益、院內各階層員工同仁工作滿意，提昇醫療服務品質，本研究目的：
(1)藉著宏觀的系統思考方式，探討個案醫院實施健保TW-DRGSs制度時，住院時間之管理對個案醫院長期營運之影響，並能協助個案醫院找到最適的管理成效。
(2)建立系統動力學模式，模擬個案醫院分年分階段實施健保TW-DRGSs制度時住院天數之管理對醫院收支、醫療行為與醫病關係之影響。
本研究具體建議如下：
(1) 控管住院天數，增加病床周轉率
(2) 建立各類疾病臨床指引或臨床路徑
(3) 提高醫療費用申報效益
(4) 自費項目開發之研究

Since the systems of health insurance of the whole people were run in March of the 84th year of the Republic of China, it is very near to offer medical treatment to the best patient in the whole world, the highly free right to choose of seeking medical advice, and high-quality medical care. But cause the expense expenditure of the hospital to rise continuously, is strong in protecting the office as because in conformity with the financial situation, pursue a lot of financial retrenchment policies successively, cause uncertainty and complexity of the medical industry''s environment. Especially pay the system so far the total value of the hospital, decline in the development in economy of the whole world depressedly, domestic aging of population, unemployment increase, medical resources are insufficient day by day and strong in assuaring the financial affairs are left pressingly, the central health insurance bureau is paid the system and controls the cost, adjust and pay the standard progressively, towards pay, standardize while being single, so reform pay medical the intersection of institutes and way pay system for TW-DRGSs '' diagnose related group in hospital '' stage by stage year by year from January of 1999.
Made in Singapore after setting out on a journey, future so long as medical resource more close part will be sorted out into the same class, in accordance with kinds of Diseases, operation, age, gender, amalgamate condition classification such as disease, divide into groups according to the weight grade of the condition, pay by norm, is lower than lower limit, will adopt and verify that declare the way, that is to say '' pay the system with severity and reward ''. The government implements the policy purpose of '' TW-DRGSs '', except the efficiency of serving for raising medical treatment, reduce the waste, also can improve patient, look after quality and curative effect, let the intersection of hospital and the intersection of cost and optimization, but the implementation of DRG will cause the suitable impact of the hospital, may aggravate looking after and financial responsibility and risk of the medical organization.
But hospital attribute( Set objectives, the intersection of role and localization, organization and the intersection of power and responsibility and structure,etc.) Different, the hospital faces being strong in assuaring that it and because will be different to pay the financial pressure that the system changes in conformity with ways, except army''s hospital in the country shoulders the country and looks after soldier''s healthy policy responsibility, pay attention to managing the performance even more. So because should be strong in assuaring that it will be different to pay measure and efficiency that the system''s changing takes and lowers costs to some extent, and these differences will react on the manifestation of financial performance indicators such as its medical care amount, income and interests,etc.. Satisfied how to promote the financial performance of the hospital, give consideration to operations objective, medical care quality and patient of the hospital at the same time, key factor that will be managed continuously forever for the hospital.
Until '' diagnose related group in hospital '', first serious the intersection of case and clinical route standardize, influence clinical the intersection of route and standardization make, act as, in hospital number for the first time, so this research institute builds the systematic dynamics model constructed, the ones that chose the first stage to implement 155 items of TW-DRGSs were in hospital in days, the hospital TW-DRGSs case number, take bed rate and satisfaction in hospital etc., these influence each other the simulation of the relation value adopts Table function to imitate. And Table function which this research institute puts forward passes the true data in often operation course on ordinary days of case hospital, observe and experience judgement or relevant literature consult materials of income, performance its weigh the intersection of indicator and system can represent the intersection of country and the intersection of army and the intersection of hospital and case only, can''t prove why the other scale hospitals are appropriate; And this research is paid and imitated according to the systematic way of case hospital alone, as system way may present different results not simultaneously.
Expect to give the case hospital some suggestions in managing, managing and is made with the clinical route through this research, the colleagues of staff of different levels work satisfiedly in safeguarding patient''s whole rights and interests, courtyard, promote the quality of medical care, the purpose of this research:
(1)Make use of system of macroscopic think way, canvass the intersection of case and hospital, implement, good for, protect TW-DRGSs at the system, the influence that the management in hospital stays runs to the case hospital for a long time, and can assist the case hospital to find the optimum management effect.
(2)Set up systematic dynamics way, imitate the intersection of case and hospital, divide into annual to implement, good for, protect TW-DRGSs, in hospital management of day to the intersection of hospital and revenue and expenditure, medical behavior and influence to cure the desease relation at the system stage by stage.
The concrete suggestion of this research is as follows:
(1) Control and manage number in hospital, increase the turnover rate of the sick bed
(2) Set up all kinds of disease clinical guiding or clinical routes
(3) Improve the hospitalization cost and declare benefit
(4) Research of project development at one''s own expense

誌謝 II
中文摘要 III
ABSTRACT V
目錄 VIII
表目錄 XI
圖目錄 XII


第1章 緒論 1
1.1研究背景 1
1.2研究動機 1
1.3研究目的 2
1.4研究流程 2
1.5研究架構 4
第2章 文獻探討 5
2.1 前言 6
2.2健保支付制度簡介 6
2.2.1論服務量計酬 6
2.2.2論病例計酬 6
2.2.3總額預算支付制度 6
2.2.4 DRG診斷關聯群支付制度 8
2.2.5 DRG名詞解釋 13
2.3住院日數與醫療費用之研究 16
2.4住院日數、疾病嚴重度與醫療費用之相關研究整理 16
2.5個案醫院簡介 18
2.5.1個案醫院之沿革 18
2.5.2經營理念與願景 18
2.5.3營運現況 19
2.5.4個案醫院 TW-DRGs導入後占全部住院費用之影響 19
第3章 研究方法 23
3.1系統思考 23
3.2系統動力學 25
3.2.1資訊回饋環路 26
3.2.2時間滯延 26
3.2.3動態性複雜 26
3.2.4處理非線性問題 27
3.3因果回饋圖 27
3.4繪製因果關係圖應注意的事項 30
3.5 系統動力學基礎模型 31
3.5.1線流圖 31
3.5.2積量 31
3.5.3 率量 31
3.5.4輔助變數 32
3.5.5 關係 32
3.6系統動力學模擬軟體 33
3.6.1 DYNAMO 33
3.6.2 Vensim 33
3.6.3 Powersim 34
3.6.4 STELLA 34
3.7系統建模程序 34
3.8模型測試及效度檢驗 39
第4章 系統動力學模型建構與政策模擬分析 41
4.1系統動力學基礎模型 41
4.1.1個案醫院之問題描述與系統邊界 41
4.1.2因果回饋分析 41
4.1.3系統動力學架構 45
4.1.4信度與效度檢定 51
4.2情境模擬 54
4.3情境分析 57
4.4政策分析 57
第5章 結論與後續研究建議 60
5.1研究發現與結論 60
5.2研究貢獻 60
第6章 參考文獻

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網路部分
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(4)衛生署中央健康保險局住院診斷關聯群支付制度主題專區 網址：http://www.nhi.gov.tw/webdata/webdata.asp?menu=5&menu_id=463&webdata_id=937&WD_ID=463