精神醫療機構對健保論質計酬的態度與預期醫療服務的變化

(1)

(2)

2000

Sederer

Sederer 1987

Mihalik

Mi-halik

1988

(3)

2000

2002

2000

1988

66.4%

2000

1997

2001

1999

1997

2001

Dorwart

Dorwart, 1991

Horwitz &Scheid

(4)

29.5%

26.4%

15.7%

9%

8 . 6 %

5%

2.9%

Horwitz &

Scheid 1999

2000

_{SPSS 8.0}

cronbach

0.8448

3

(5)

34

94

62

17

13

20

5

22

92

267

3

166

62.1 /

/

(6)

91

14 VS 14-65 VS 65 VS VS VS VS VS VS VS VS VS VS VS

(7)

166

44

42.8

42.7

13.2

166

144

166 25.7%

18%

11.2%

7.2%

17.3%

14.4%

11.8%

19.4%

(8)

ᖂኵ 267 ӱԝ 166 њП঄ p঄ ᚂᕛ଱ܚȞᚂ଱ᇄຨܚȟ 190 122 ஶඈϞЄڞོ 22 9 12.00 0.213 ᚂ଱ߣ೩ᇄᐿҳஶඈϞড় 37 24 ᐠᄺ ᚂ଱ߣ೩ᇄᐿҳޥୢඈ୊ϛЖ 18 11 ᚂᏰϛЖ 12 6 ୢ୿ఀᏰᚂ଱ 43 29 ୢ୿ᚂ଱ 8 3 ӴୢఀᏰᚂ଱ 16 14 Ӵୢᚂ଱ 15 14 9.64 0.95 ᆠડடऋᚂ଱ 18 15 ᆠડடऋఀᏰᚂ଱ 16 16 ଱ܚቹ઻ ຨܚ 62 26 ѮѕӴୢȞѕȃஅȃۣȃߜȃ଻ȟ 89 60 ѕഋӴୢȞੀȃԼȃऻȟ 21 18 ϛഋӴୢȞᄔȃϛȃ׹ȟ 44 24 ࠒഋӴୢȞ໴ȃოȃࠒȟ 46 27 5.66 0.87 ଽࡎӴୢȞଽȃࡎȃዙȟ 53 24 ᐠᄺܚӵӴ ݍୢȞ߆ݍȟ 14 13 ဍѿᑪҳᚂ଱ 49 44 ୽ॖᚂ଱ 9 8 ሄᏲོᚂ଱ 18 17 ୽ҳᚂ଱ 2 2 10.76 1.00 ؽҳᚂᏰ଱ߣ೩ᚂ଱ 5 1 ଒ღݲΡܖ۠ఀᚂ଱ 42 28 ᠌ ឴ տ ؽΡᚂ଱ 37 29

(9)

ғөᄘ࡙ ල೽ᄘ࡙ ॒өᄘ࡙ Ґ༲ ᕣ၌ 73)44%** 71)42.8%* 21)12.6%* 3)1.8%* ᜓԙ 22)13.2%* 70)42.2%* 71)42.7%** 3)1.8%* ᄘ࡙ ໶Ҭ Ρኵ)%* ғөᄘ࡙)%* ල೽ᄘ࡙)%* ॒өᄘ࡙)%* Ґ༲)%* 1.୊߳׋џоᎌ࡙ॏۡЛпᘈኵܖߜ᚞ 89)618%** 22)15.3%* 30)20.8%* 3)2.1%* 2.Ϛོഅԙᐠᄺ໢ޟᝯތڷፐए 31)21.5%* 16)11.1%* 96)66.7%** 1)0.7%* 3.ϚོഅԙၶӻޟМਪώհ 35)24.3%* 25)17.4%* 83)57.6%** 1)0.7%* 4.ᚂᕛᐠᄺԤၶσኆܒЅཎ᜹ඪټ؁ᐌ ᡝޟ݈୛ 59)41%** 24)16.7%* ₅₉_)41%** 2)1.4%* 5.Ϛོᇶีᚂৱ౰ҡ୑৯՗࣏ᒵᐅၶ୊ ஶޟএਰԝᕛ 27)18.8%* 15)10.4%* 101)70.1%** 1)0.7%* 6.ᐠᄺϚོᕻ฻੾Ρޟ՞଱Јኵ 32)22.2%* 30)20.8%* 81)56.3%** 1)0.7%* 7.џоጂ߳ᚂᕛࠢ፴ 45)31.3%* 37)25.7%* 61)72.4%** 1)0.7%* 8.ᚂᕛࠢ፴џᙤҥॏۡശճሯؑپᅿ௡ 80)55.6%** 30)20.8%* 33)22.9%* 1)0.7%* 9.ҧൢЙ៉ᙏ൐ 61)42.4%** 42)29.3%* 40)27.8%* 1)0.7%* 10.୊߳ቷࢥџۡಛΙ኿ྥ 70)40.8%** 35)24.3%* 38)26.4%* 1)0.7%* 11.୊߳׋ৠܾॏۡᆠડऋႱᆗ 88)61.1%** 28)19.4%* 21)18.1%* 2)1.4%* 12.ᚂᕛၥྛȞ֤ޥୢȟџӫ౩Ϸ଩ 49)34%* 33)22.9%* 61)42.4%** 1)0.7%* 13.੾Ρޟ՞଱Јኵ۽ߝ 25)17.4%* 38)26.4%* 76)52.8%** 5)3.5%* 14.ҧൢЙ៉ፒᚕ 45)21.3%* 56)38.9%** 40)28.5%* 2)1.4%* 15.ᐠᄺོӰԪЛпڙ࡙Մᕕց 17)11.8%* 49)34%* 77)53.5%** 1)0.7%* 16.੾Ρ൷ᚂޟП߯ܒுڗ׽๡ 34)23.6%* 44)30.6%* 64)44.4%** 2)1.4%* 17.᛾ቋЅ᛾໔ོ໌Ι؏ுڗ௡ڙ 78)54.2%** 36)25%* 28)19.4%* 2)1.4%* 18.੾Ρᅖཎོ࡙ுڗඪ݇ 35)24.3%* 48)33.3%* 60)41.7%** 1)0.7%*

(10)

)

(

ᄘ࡙ ໶Ҭ Ρኵ)%* ቨ >10% ё <10% Ϛᡐ ෵ >10% Ѝ <10% Ґ༲ 1.ߞຨຨԩ 22)13.9%* 17)11.8%* 41*)28.5%* 8)5.6%* 7)4.9%* 51)35.4%* 2.ࡨຨΡԩ 13)9%* 13)9%* 40*)27.8%* 7)4.9%* 1)0.7%* 70)48.1%* 3.੾חኵ ࡨܒ 8)5.6%* 8)5.6%* 38*)26.4%* 10)6.9%* 7)4.9%* 73)50.7%* ᄚܒ 4)2.8%* 6)4.4%* 39*)27.1%* 10)6.9%* 8)5.6%* 77)53.5%* Р໢ 12)6.9%* 15)10.4%* 32*)23.2%* 1)0.7%* 1)0.7%* 85)59%* 4.ޥୢᆠડᚂᏰ ޥୢඈ୊ϛЖ 14)9.7%* 7)4.7%* 34*)23.6%* 1)0.7%* 1)0.7%* 87)60.4%* ஶඈϞড় 12)8.3%* 5)3.5%* 48*)33.3%* 2)1.4%* 2)1.4%* 75)52.1%* ۨড়ݽᕛ 14)9.7%* 14)9.7%* 24*)16.7%* 2)1.4%* 1)0.7%* 89)61.8%* 5.ޥࢇחኵ 10)6.9%* 5)3.5%* 34*)23.6%* 1)0.7%* 1)0.7%* 96)64.6%* 6.᛾᠓חኵȞϴາחȟ 2)1.4%* 3)2.1%* 36*)28%* 3)2.1%* 1)0.7%* 99)69.3%* ᛾᠓חኵȞՌາחȟ 6)4.2%* 5)3.5%* 34*)23.6%* 1)0.7%* 1)0.7%* 97)67.4%* 7.ড়ኸ٩ݽΡԩ 5)3.5%* 9)6.3%* 41*)28.5%* 0)0%* 1)0.7%* 88)61.1%* 8.ܒ߭৛٩ݽΡԩ 5)3.5%* 9)6.3%* 42*)29.2%* 0)0%* 1)0.7%* 87)60.4%* 9.Ԟ෈ᕛىחኵ 5)3.5%* 3)2.1%* 37*)25.7%* 0)0%* 3)2.1%* 96)66.7%*

(11)

14 VS

VS

1

1 2000

74.8%

61.8%

83.9%

21.3%

54.2%

(12)

அҏ੫ܒ ᐠᄺ ឴ܒ ቹ઻ ᙛ୛ Ӵ౩՝ည ॎᖠ ᕕցܒ 1.୊߳׋џоᎌ࡙ॏۡ Лпᘈኵܖߜ᚞ ฒཎَܖ Ϛӣཎ VS ӣཎ 3.681 ).29* 3.042 ).38* 2.061 ).56* 5.326 ).503* 11.477 ).244* 2.822 ).516* 12.412 ).191* 2.Ϛོഅԙᐠᄺ໢ޟᝯ ތڷፐए ฒཎَܖ Ϛӣཎ VS ӣཎ .081 ).96* .804 ).669* 4.945 ).084* 4.212 ).378* 13.649* ).034* 7.782* ).02* 18.804* ).005* 3.ϚོഅԙၶӻޟМਪ ώհ ฒཎَܖ Ϛӣཎ VS ӣཎ .13.8* ).01* .569 ).75* .917 ).632* 5.798 ).215* 2.665 ).85* 2.837 ).242* 16.584* ).011* 4.ᚂᕛᐠᄺԤၶσኆܒ Ѕཎ᜹ඪټ؁ᐌᡝޟ ݈୛ ฒཎَܖ Ϛӣཎ VS ӣཎ 2.319 ).51* 1.487 ).68* 1.352 ).717* 4.212 ).148* 4.065 ).907* 1.067 ).785* 19.212* ).023* 5.Ϛོᇶีᚂৱ౰ҡ୑ ৯՗࣏ᒵᐅၶ୊ஶޟ এਰԝᕛ ฒཎَܖ Ϛӣཎ VS ӣཎ .305 ).85* 1.751 ).42* 3.069 ).216* 3.272 ).513* 6.48 ).372* 3.078 ).215* 3.534 ).739* 6.ᐠᄺϚོᕻ฻੾Ρޟ ՞଱Јኵ ฒཎَܖ Ϛӣཎ VS ӣཎ 1.836 ).39* 5.789 ).55* 1.285 ).533* 5.291 ).259* 10.005 ).122* 3.18 ).204* 9.743 ).136* 7.џоጂ߳ᚂᕛࠢ፴ ฒཎَܖ Ϛӣཎ VS ӣཎ 1.371 ).71* 2.523 ).47* 7.327 ).062* 13.852* ).031* 8.772 ).459* 2.386 ).496* 22.787* ).007* 8.ᚂᕛࠢ፴џᙤҥॏۡ ശճሯؑپᅿ௡ ฒཎَܖ Ϛӣཎ VS ӣཎ .587 ).74* 2.987 ).22* 7.45* ).024* 8.806 ).066* 14.403* ).025* 3.555 ).169* 14.315* ).026* 9.ҧൢЙ៉ᙏ൐ ฒཎَܖ Ϛӣཎ VS ӣཎ 7.693* ).02* .059 ).97* 1.086 ).578* 7.866 ).097* 11.597 ).072* 9.57 ).62* 11.232 ).081* 10.୊߳ቷࢥџۡಛΙ኿ ྥ ฒཎَܖ Ϛӣཎ VS ӣཎ 2.557 ).27* .458 ).79* .312 ).856* 2.51 ).643* .592 ).47* .238 ).888* 19.859* ).003* 11.୊߳׋ৠܾॏۡᆠડ ऋႱᆗ ฒཎَܖ Ϛӣཎ VS ӣཎ 1.22 ).54* .022 ).98* 1.44 ).487* 1.527 ).822* 6.501 ).37* 4.08 ).129* 16.201* ).013* 12.ᚂᕛၥྛȞ֤ޥୢȟ џӫ౩Ϸ଩ ฒཎَܖ Ϛӣཎ VS ӣཎ 7.674* ).02* .235 ).88* 1.057 ).59* 9.991* ).041* 18.652* ).005* 6.898* ).032* 16.4* ).012* 13.੾Ρޟ՞଱Јኵ۽ߝ ฒཎَܖ Ϛӣཎ VS ӣཎ .889 ).64* .632 ).72* .736 ).692* 3.105 ).54* 13.986* ).03* 5.085 ).079* 7.711 ).26* 14.ҧൢЙ៉ፒᚕ ฒཎَܖ Ϛӣཎ VS ӣཎ 2.382 ).30* .344 ).84* .537 ).76* 6.031 ).197* 12.657* ).049* 2.376 ).305* 11.503 ).074* 15.ᐠᄺོӰԪЛпڙ࡙ Մᕕց ฒཎَܖ Ϛӣཎ VS ӣཎ 1.838 ).39* 2.542 ).28* 4.628 ).099* 4.445 ).349* 12.385 ).054* .12 ).942* 12.863* ).045* 16.੾Ρ൷ᚂޟП߯ܒு ڗ׽๡ ฒཎَܖ Ϛӣཎ VS ӣཎ 1.518 ).67* 5.169 ).16* 2.959 ).228* 8.266 ).219* 5.052 ).83* 4.566 ).206* 17.362* ).047* 17.᛾ቋЅ᛾໔ོ໌Ι؏ ுڗ௡ڙ ฒཎَܖ Ϛӣཎ VS ӣཎ 2.652 ).44* 4.226 ).23* 4.4942 ).213* 6.541 ).375* 15.138 ).087* 2.032 ).566* 18.561* ).029* 18.੾Ρᅖཎོ࡙ுڗඪ ݇ ฒཎَܖ Ϛӣཎ VS ӣཎ 1.14 ).56* 1.94 ).37* 2.21 ).33* 5.5 ).237* 7.897 ).246* 2.684 ).261* 20.182* ).043* p p 0.05

(13)

2 66.7%

11.8%

53.5%

47.7%

40.8%

3 56.3%

41%

70.1%

໶Ҭ ߞຨ ࡨܒ ੾ܘ Р໢ ੾ܘ ஶඈ Ϟড় ޥୢඈ ୊ϛЖ ۨড় ݽᕛ ޥࢇח ᛾᠓ )Ռ* ড়ኸ ٩ݽ ܒ߭৛ ٩ݽ ᐠᄺ)ᚂ଱ VS ඈ୊* 1.23 .29 ឴ܒ)ϴҳ VS ؽҳ* .223 2.725 2.319 2.494 1.458 4.61* 3.356 10.6* 1.319 1.414 ቹ઻)ᆣӫ VS டऋ* 1.89 2.36 1.017 4.194* 4.473* 2.54 6.603* 10.9* 1.913 1.967 ɵ65 ྑΡο% .582 .717 .761 1.007 1.593 .327 4.978 3.355 .77 .788 Р໢੾ܘחኵ .554 .38 1.467 .559 .183* .554 6.69* .697 1.606 1.579 ᕕց 1.808 3.764 10.04* .684 16.02* .4003 1.611 1.46 .367 .376 1 * _p _0.05 ₂ _VS p 0.05

(14)

54.4%

70.1%

52.8%

35.6%

56.3%

42.4%

17.6%

34%

4 5 3 . 5 %

7 2 . 4 %

41.7%

45.7%

55.6%

Ellsbury

K 1990

(15)

/

2. Shern, DL

Shern D L, Donahue S A, Felton C,

etal 1995

VS

(16)

1988

VS

(17)

1 1998

32

6 15-20

2 1998

31:1-13

30-49

4 2000

61-65

:

5 2002

11 15-22

6 2001

72

7 1997

53-54

8 1999

92-96

9 1997

6-16

10 2001

41

11 2000

82

(18)

19

5

13 1988

84 14. Orwart RA, Schlesinger M,

Davis-don...et al (1991). National study of

psy-chiatric hospital care. Am J.Psychiatry,

148:204-10.

15. Horwitz AV, Scheid TL A (1999).

Handbook fotr the study of Mental

Health. United Kingdom. Cambridge

University Press.

16. Mechanic D.MeAlpine D. Olfson M.

(1998). Changing Pattern of

Psyhchi-atric Inpatient Care in the United States.

1988-1994, Archives of General

Psychi-atry, 785-91

17. Sederer L I (1987). Utilization ReView

& quality assurance: Staying in the

black & working in the blue. General

Hospital Psychiatry, 9(3):210-19.

18. Mihalik G J (1988). Accreditation in

managed behavioral health care: in

in-terview with Mary ceasare-murphy and

Sharda. Journal of Health Care Finance,

spring, 24(3)51-65.

19. Ellsbury K (1990). Attitudes of

Wash-ington state primary care physicians

toward capitation-base insurance plans.

The Journal of Family Practice, 30(1):

89-94.

20. Shern D L, Donahue S A, Felton C. et al

(1995). Partial capitation and fee for

service in mental health care. Health

Af-fairs, 14(3):208-19.

(19)

Object: To analyze the relation between mental health institutes

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attitude

toward quality-based payment system and the change of mental health services.

Method: This cross-sectional study was conducted by the same responders

of the mental health institutes that provide mental health services. Author used

questionaires to survey psychiatric rehabilitation institutions and psychiatric

clinics in Taiwan. Author surveyed their attitudes and alterations of their

ser-vices, I used bivariate analysis to analyze their attitudes and used logic

regres-sion to analyze the alterations of mental services. Author mailed 267

question-aires, 166 was returned and the response rate was 62.5%

Result: Their attitudes to quality-based payment system were pessimistic.

More than 60% of responders thought that insurance unit can set appropiate

money for services and set the psychiatry budget more easily. More than 70%

responders thought that conflicts between institutes may happen and deviant

be-haviors may be induced. In general, most mental institutes havn

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t done any

alter-ation in their services. If there is service volume changes, most of them prefer

increasing their service items which cost lower such as OPD, day-care ward, and

home visit services. Community service is related to institute profitability and

institute level. Community psychiatry set up under quality-base payment system

is related to institute profitability, institute level and institute belonging.

(20)

Conclusion: About 70% of our responders thought that there are more

dis-advantages than dis-advantages about the design of quality-based payment system.

Furthermore, the majority of mental institutes haven

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t changed their service

be-cause of the change of payment system. Most of the responders were pessimistic

to the profitability after the quality-based payment is started.