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題名：健保支付制度變遷下西醫診所回應行為之研究
作者：黃英家
作者(外文)：Ying-Chia Huang
校院名稱：雲林科技大學
系所名稱：管理研究所博士班
指導教授：林尚平
學位類別：博士
出版日期：2005
主題關鍵詞：Cox比例危害模型；組織因應行為；Kaplan-Meier存活曲線；私人診所；全民健康保險；制度變遷；private clinics；National Health Insurance；institutional change；organizational responses；Kaplan-Meier survival curve；Cox proportional hazard model
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體制變遷下中小企業因應行為的研究，因為缺乏決策行為的檔案紀錄，因此在過去相關的實證性研究並不多見。從台灣西醫基層醫療產業的特性，加上十年來台灣實施全民健康保險和總額支付制度的背景，本研究以不同於過去橫斷面相關要素分析的研究方法，嘗試進行準實驗性質的因果關係實證研究。研究中利用流行病學存活分析的概念，使用Kaplan-Meier曲線分析與Cox比例危害模型等工具來追蹤健保特約西醫基層私人診所在面對2002年起大幅調動的支付標準衝擊時會有哪些的因應決策行動。
本研究將全台灣健保特約西醫基層私人診所2001年的相關資料蒐集後依照四分位分為四群，並將75百分位組在90百分位處切為兩組，一共五組，進行回溯性世代研究，架構上粗分為診所過去經營規模、產業環境、診所專有屬性與負責醫師特質四個面向，來觀察經營模式是否因為2002年支付標準改變而有所因應行動。
研究結果顯示不論多聘醫師或處方釋出的因應行為在件數規模上都有正向相關，前者的幅度也大於後者。至於產業環境方面，分區在多聘醫師的因應行為上並無顯著差異。在處方釋出的因應行為採用方面，中區與高屏區的診所明顯少於北台灣的同儕；南區診所有分兩階段採用的傾向，各於六個月後與一年後處方釋出以因應變局。另外，城鄉差距在多聘醫師的因應行為上無顯著差異；控制件數規模後，發現都市化一、二級地區中較高件數規模的單獨執業者比其他地區同儕有較高的多聘醫師因應行為。都市的診所在處方釋出行為上，比城鎮與鄉村的診所少約四分之一；控制件數規模後，發現件數規模中量組別中，鄉村與城鎮的診所的處方釋出比例都遠高於都市診所；同時，中高量組別中，鄉村診所處方釋出比例較高，而都市診所比例較低。
在診所特性部分，以診療費高低分成三個族群。在多聘醫師的因應行為上，中診療費組的診所稍高於其他兩組，有顯著差異；控制執業型態後，發現差異來自於單獨執業的診所有較高多聘醫師的因應行為所致。低診療費組則在處方釋出的因應行為上稍高於其他兩組，有顯著差異；控制執業型態後，發現差異來自於較多聯合執業者採取處方釋出所致。若論及診所經營型態，聯合執業者，在兩種決策的採用上都遠比單獨執業者高，有顯著差異。尤其多聘醫師的因應行為高達3.3倍，但在處方釋出方面則只高三成左右；控制件數規模後，發現件數規模低量組與中低量組中，聯合執業者比單獨執業者採用了較多的多聘醫師因應行為；處方釋出方面則無顯著的差異。
在診所負責醫師屬性的分析上，分成青、中、高三個世代。在多聘醫師的因應行為上，可以見到青年組高於中年組，並遠高於高年組。控制執業型態後，發現單獨執業診所中的青年組與中年組在多聘醫師因應行為方面，是高年組的3.6倍與1.6倍；聯合執業者反而無世代之間的差異。至於處方釋出方面，青年組與中年組則比高年組多56％與33％，而且不論是否聯合執業，都存在類似的顯著差異；控制件數規模後，發現高年組醫師單獨執業者有較保守的處方釋出行為。比較負責醫師的出身時，發現本國醫學院校畢業的負責醫師多聘醫師的因應行為遠低於其他背景者；控制執業型態後，發現單獨執業組別診所之多聘醫師行為明顯低於其他背景出身者，約一半左右。但在處方釋出的因應行為上，本國醫學院校畢業者反而約比其他背景者多七成採用；控制執業型態後，發現差異在於單獨執業診所部分，聯合執業者並不顯著。最後性別因素，在多聘醫師與處方釋出的因應行為上，皆無顯著差異。
本研究並進一步以組織生態理論與體制理論中組織同形、組織惰性與利基的觀念來討論，為何在同樣的體制場域下，部分理應有所反應的診所卻保守地以過去的經營策略來面對體制環境的變動。
There were just a few studies about organizational strategic responses to the impact of the institutional change in the past. Lack of documentation of strategic decision-making, the empirical studies about small enterprises’ strategic responses to environmental change are few. Comparing to the cross-section studies, we designed a quasi-experimental cohort framework to establish a cause-effect analysis of the institutional change and organizational strategic responses. This study focused on the primary care industry of Taiwan, and based on the context of the National Health Insurance (NHI) program and the Global Budget Reimbursement System. Dividing the private clinics into 5 groups by their average outpatient visits in 2001, this study traced the responses of private clinics to the change of 2002 NHI reimbursement schedules for 31 months. Borrowing the survival analytic tools from the epidemiological methods, such as Kaplan-Meier curves and Cox proportional hazard models, the study compared the trends and the relative hazard rates between the groups based on environmental attributes and the characteristics of clinics and their owners.
The results revealed that more clinics with higher volume of outpatient visits adopted ‘one more doctor’ or ‘an affiliated pharmacy’ strategy. Though there was no difference in adopting ‘one more doctor’ strategy among different jurisdictions, clinics in Central and Kaoping jurisdictions adopted ‘an affiliated pharmacy’ strategies half less than those in other jurisdictions. There was either no difference among clinics in rural or urban areas in adopting ‘one more doctor’ strategy, but less clinics in metropolitans and cities adopted ‘an affiliated pharmacy’ strategy than those in rural areas. Dividing the clinics into three groups by the monthly claims of Treatment Fees (TF), it revealed that the middle TF group adopted ‘one more doctor’ strategy, and the low TF group adopted ‘an affiliated pharmacy’ strategy more than other groups. Group-practice clinics were 3.3 times more than those sole-practice ones to adopt ‘one more doctor’ strategy, but 30% more in using ‘an affiliated pharmacy’ strategy. According to the ages of the clinic owners, it found that younger and middle cohorts were 3.6 and 1.6 times more than elder one in adopting ‘one more doctor’ strategy, but only 56% and 33% more in using ‘an affiliated pharmacy’ strategy. Clinic owners graduated from Taiwan’s medical schools adopted ‘an affiliated pharmacy’ strategy more, but used ‘one more doctor’ strategy less than the others. There was no gender difference in strategic adoption. There was more detail analysis of organizational isomorphism, inertia, and environmental niche in the discussion.
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