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題名:牙醫總額支付制度分區成效差異原因探討: 中區與南區之比較
作者:陳順義
作者(外文):Shun Yi Chen
校院名稱:國立中正大學
系所名稱:社會福利系
指導教授:鄭文輝
學位類別:博士
出版日期:2002
主題關鍵詞:總額預算總額支付制度共有財產資源牙醫醫療服務Global BudgetGlobal Budget SystemCommon-Property ResourcesDental Care
原始連結:連回原系統網址new window
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「總額支付制度」被視為解決全民健保財務收支問題以及管控醫療費用合理成長的有效機制之一。我國自民國八十七年七月開始「試辦」牙醫門診總額支付制度;中醫、西醫基層、西醫醫院等總額支付制度亦陸續實施。總額支付制度實施之後,是否會造成醫療提供者之間的惡性競爭,爭食固定預算「大餅」,進而影響總額支付制度實施成效?其影響原因為何?頗受關切;惟國內文獻對此方面之研究似乎付諸闕如,本文試圖彌補此一缺口。
在健保六分區當中,牙醫總額各區實施成效有所差異,南區是截至目前為止區域總額實施較為「成功」的案例;而中區的點值、爭議審議案件量、醫療服務量等指標比較「極端」,是較為「異常」的案例。同樣的總額支付制度,同樣是牙醫系畢業的醫師,為何兩區實施成效不同?頗直探究。在研究方法上,本文係採用多元方法(包括深度訪談、文獻分析及準統計方法)加以探討分析。
我國目前實施的總額預算搭配論量計酬的方式類似共有財產資源,因此本文嘗試從共有財產資源的觀點來探討南區與中區的經驗差異,實證研究發現南區牙醫總額實施成效較佳的原因,除了情境因素與管理機制的因素之外,南區分會組織(領導階層)能夠有效地建立並累積「社會資本」,更是促進同儕合作的關鍵因素;亦即南區分會組織較能透過正式制度與非正式制度來克服搭便車問題或投機主義,促進牙醫師會員的合作,因而使得牙醫總額區域預算(共有財產資源)的使用不致於落入「共有資源悲劇」的結果。本論文實證結果挑戰賽局理論方法認為「人類是理性、狹隘自利、短視的極大化者,因而總是會背叛」的論點(迷思)。在政策意涵上,全聯會以及政府主管機關有必要根據各區實施成效,發現「病因」加以「對症下藥」,改善制度的缺失,以利總額支付制度的「永續經營」。
Taiwanese government implemented the Global Budget System for dental care on July 1, 1998. Compare the outcomes between the six NHI districts, South Taiwan district is the most successful, while Mid-Taiwan district is more “extreme” or deviant. Since a global budget married to fee-for-service payment is directly analogous to a common-property resource (CPR), we use a framework of common-property resource to explore the difference of outcomes of management between Mid-Taiwan district and South Taiwan district, and to discuss the policy implications about institutional design and financial incentives.
Theoretically, a successful and sustainable management of such CPR — global budget─depends on the contextual factors and management arrangements. We use a multi-method to explore the different experience between the two NHI districts. Through empirical research, we find South Taiwan district is more successful than Mid-Taiwan district because: 1). The global budget in Mid-Taiwan district put greater economic pressure on its dentists than did it in South Taiwan district; 2). The management arrangements of South Taiwan district are more effective to overcome the free-rider problem of collective action and to foster the cooperation among dentists. 3). Surprisingly, the leaders of Dentist Association of South Taiwan district can directly and indirectly accumulate the “social capital”(e.g. trust) to strengthen the cooperation among dentists. Our research results challenge the myth of game theory method presupposing ‘human beings are rational, narrowly self-interested and myopic maximizer so that always defect’.
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蘇鴻輝(2000),由牙醫總額制度的轉折看整體健保醫療環境的改變:牙醫界如何自處之省思,http://www.tda.org.tw
二、英文部分
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