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題名：總額預算制度下醫院所有權結構與營運績效關係之研究
作者：劉惠玲
校院名稱：國立政治大學
系所名稱：會計研究所
指導教授：吳安妮
學位類別：博士
出版日期：2009
主題關鍵詞：總額預算制度；支付點值；核減率；財務衝擊；所有權結構；營運效率；醫療品質；財務績效；global budget system；floating point-value system；deduction rate of claim；hospital ownership；operational efficiency；quality of care；financial performance
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所有權結構、支付制度與競爭係影響醫院績效之關鍵因子，本研究援用相關文獻之發現，推論出三項因素對醫院績效之關係，並以我國獨特之總額預算制度為研究對象，蒐集、串連與合併不同來源之資料，實證檢視衝量競爭與所有權結構對醫院營運績效與醫療品質之聯合效果。
台灣於民國91年7月實施醫院總額預算制度後，浮動點值制度之設計為醫院間引入了衝量競爭(即虛假價格競爭)，而結算後之點值則係反映出醫院間衝量競爭後之結果，醫院除了需面對支付點值所致之財務衝擊外，尚須面對自全民健保實行後，備受醫院詬病之核減制度之衝擊，因此，本文首先嘗試估算醫院受到核減與支付點值所致之財務衝擊程度。無論是國外或國內之研究，對於不同所有權結構醫院之績效表現是否有差異性，一直無法獲得一致性之結論，除了納入營運效率之績效指標外，本研究亦採用疾病別與醫院層級別之醫療品質指標來檢視不同所有權結構醫院之績效表現。更以考量核減與支付點值所致之財務衝擊程度，取代目前文獻僅以總額前、後之二元變數，評估財務衝擊程度對營運效率、醫療品質與財務績效之影響。最後，則是檢視總額預算制度下，醫院受到之財務衝擊度是否會縮小不同所有權結構醫院之營運效率與醫療品質表現之差距。
實證研究發現，不同所有權結構醫院之營運效率並未有顯著差異，但不同所有權結構醫院在某些疾病別品質指標(子宮肌瘤切除手術之住院超過7日機率與再入院率)與醫院層級品質指標(院內感染率與淨死亡率)表現上則有差異性；且公立或非營利醫院受到核減與支付點值之財務衝擊高於私立醫院，因此不同所有權結構醫院之行為與績效存有某些差異性。台灣的醫院在總額預算制度下，若受到之財務衝擊程度愈大，其營運效率會變差、醫療品質也受到負面之影響、財團法人醫院之醫務利益率與稅後淨利率也會降低，但現金流量比則會增加，故財務衝擊愈大，醫院之績效愈低。若同時考量財務衝擊度對不同所有權結構醫院之營運效率與醫療品質之聯合效果後，可發現財務衝擊雖然不會縮小公立(或非營利)醫院與私立醫院營運效率之差距，卻縮小公立(或非營利)醫院與私立醫院醫療品質之差距，故以台灣資料可部分支持「不同所有權結構醫院績效差距縮小之因素係競爭力量之崛起」之論點。
Hospital ownership, payment system and competition are all key drivers to influence hospital performance. This research infer and depict the association of these three drivers from the related literature and empirically examined the effects of fictitious price competition due to the floating point-value system and ownership on hospital operational performance and quality of care by combing and merging different sources of data.
Deduction rate of claim and the floating point-value system are the two controversial debates to the payment system. I attempt to estimate hospital financial pressures as precipitated by deduction rate of claim and floating point-value system. To investigate whether for-profit, not-for-profit, and government hospitals differ in operating performance and quality of care, five diagnose-level and two hospital-level quality indicators are selected. Different from prior research, the financial pressure is captured by hospital data instead of a binary variable (pre and post global budget) and I examine the effect of financial pressure on hospital operational efficiency, quality of care and financial performance. Finally, we test whether differences in operational efficiency and quality care among hospitals with different ownership forms will mitigate or narrow, as hospital financial pressure increases.
The results show that for-profit, not-for-profit and government hospitals are far more alike than different in operational efficiency, but ownership affects not only the rate of readmission and the rate of the length of stay larger than 7 days of uterine myomectomy, but also the hospital-level quality indicators: the rate of nosocomial infection and hospital mortality rate. I also find higher financial pressure incurred at government or not-for-profit hospitals than for-profits hospitals. Given my findings, we conclude that hospital ownership status affect performance in terms of quality of care and financial pressure from rate of deduction and float point-value system.
The study shows that financial pressure adversely affects operational efficiency and quality of care. As not-for proprietary hospital financial pressure increases, the profit margin and net profit ratio will decrease, but the cash flow ratio will increase. Nonetheless, deduction rate of claim and global budget has a negative impact on hospital performance. This research further considers the joint effect of financial pressure on difference between quality of care and efficiency of for-profit hospitals and the other two types. My results indicate that hospital financial pressure mitigates the difference of quality of care between for-profit hospital and not-for profit (or government) hospitals, but does not narrow the difference in quality of care between for-profit hospital and not-for profit (or government) hospitals. This finding partly supports that increased competition should force not-for-profit (or governmental) hospitals to be increasingly similar to their for-profit counterparts.
一、中文文獻
(一)中文期刊
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