| 摘要: | 在全民健康保險之總額預算制度影響下，導致醫院經營困難，自費醫療市場已成為近年來各醫院競相開發的重點。由於醫院大部分的醫療皆由醫師開始，本研究從醫師之角度，了解醫師對於推薦自費醫療特殊材料之認知與想法及相關影響因素。
研究對象為中部某一區域醫院及某一醫學中心之主治醫師，符合本研究對象選取條件且願意接受訪談之受訪者共有11位主治醫師，以質性研究方法採用半結構式訪談方式對研究受訪者進行訪談。
從訪談資料分析結果，醫師對於自費醫療特殊材料之看法，認為全民健保之單一保險人制度下，健保給付修訂速度跟不上新醫療項目研發推出速度，造成自費空間出現；自費醫療項目牽扯利益因素，可增加醫院健保外之營收及醫師薪資收入。受訪醫師對於推薦自費醫療特殊材料的正面觀點是對病人病情有幫助、增加病人選擇性、增加醫院或科室營收；負面觀點是讓病人誤認醫師在推銷、增加病人經濟負擔。
研究結果呈現醫師推薦自費醫療特殊材料之影響因素，(1)病人因素：醫師會考量病人的身體條件、疾病狀況及經濟能力；病人自主性提高，希望能參與醫療決策過程；若是病人有商業保險可給付、經濟條件佳、對自費項目的預期心理，將主動要求使用自費醫療項目；病人若對過度期待自費醫療項目，為了避免預期效果與期望不相符，醫師則不推薦自費醫療項目。(2)醫師因素：醫師面臨自費醫療項目經濟利益誘因與醫學倫理之拉扯，當門診忙碌、病人多、沒把握時則不會推薦。(3)醫院因素：醫院抱持贊同想法，鼓勵醫師推薦自費，採規定自費比例、獎勵措施等方式來激勵醫師推薦自費醫療項目。(4)健保局因素：醫師必須顧慮健保局之規範，不能擅自向病人推薦自費醫療項目，亦擔心病人向健保局申訴而要求醫院退費。(5)醫材廠商因素：廠商對醫院或醫師的促銷行為，及廠商所生產之醫材品質亦會影響。(6)社會團體因素：如消費者保護基金會、醫療改革基金會、政治團體、勞工或榮民團體，皆站在民眾的立場發聲，醫師認為社會團體不贊同醫師推薦自費醫療特殊材料。
本研究建議，(1)衛生主管機關：醫院提供自費醫療服務項目並非壞事，醫院除了可以穩定醫院經營成本、增加營收讓醫院永續經營，同時也能降低對健保財務資源的依賴；可以透過設立公開資訊平台及相關配套措施，保障病人權益，並宣導及教育民眾正確之醫療觀念。(2)醫院內部管理單位：在醫院經營績效與維護病人最大利益之間做出合理的平衡。(3)醫師：以病人利益為最大考量，應善盡告知義務，與病人充分溝通，以避免醫病雙方認知誤差產生誤會。
Due to the budget sum system of the national health insurance, the hospital operation encounters more difficulties, so the out-of-pocket medical market has become the focus for the hospitals to develop vigorously in recent years. As the medication is mostly started from the physicians of the hospital, this study intends to learn about the cognition, opinions of the physicians towards the out-of-pocket medical special materials, as well as the related influencing factors.
The subjects of this study are the attending physicians from a regional hospital and a medical center. We select 11 attending physicians in total who meet the selection conditions and are willing to take the interview. The qualitative study method and the semi-structural interview were adopted to interview the subjects.
According to the analysis results of the interview data, as for the physicians’ opinion towards the out-of-service special materials, they think the health insurance payment is not updated as quickly as the release and development of the new medication items under the single-payer system of the national health insurance , which results in the out-of-pocket room. Moreover, the out-of-pocket medication items, which involve the financial benefits, can increase the revenue of the hospital and the income of the physicians out of the national health insurance. The subjects hold both the positive view and the negative view towards recommending the out-of-pocket medical special materials. The positive view is that it is helpful to the illness, provides more options to the patients, and increases the revenue of the hospitals or departments. On the other hand, the negative view is that the patients think the physicians are promoting the out-of-pocket medical special materials which will burden the patients more.
The study results show the factors that influence the physicians to recommend out-of-pocket medical special materials, as listed below. (1) Patients: the physicians will consider the situation of the patients, such as the physical condition, illness and economic capabilities. If the patients can get the payment from the commercial insurance, and have good financial condition, they will ask for the out-of-pocket medication items themselves. If the patients have quite high expectation, the physicians won’t recommend the out-of-pocket medication items in case the effect is inconsistent with the expectation. (2)Physicians: the physicians are faced with the economic incentives of the out-of-pocket medication items and the medical morality. Thus, they won’t make recommendation when they are busy with the outpatient work, or they have too many patients or they are not confident enough. (3)Hospital: the hospital encourages the physicians to recommend the out-of-pocket medication based on certain proportions and some incentive policies. (4)Health Insurance Bureau: the physicians must consider the regulations formulated by the Health Insurance Bureau, and they can’t recommend the out-of-pocket medication items randomly concerning the patients will make complaints to the Health Insurance Bureau and ask for refund of the hospital. (5)Medical materials supplier: the promotion of the supplier to the hospital or the physicians, as well as the quality of the medical quality, also shows influence. (6)Social communities: the social communities such as the Consumer Protection Foundation, Medical Revolution Foundation, Political Community, Labor Union or Veteran Community, all speak for the citizens. The physicians don’t think the social communities agree with their recommendation of the out-of-pocket medical special materials.
This study proposes the following suggestions. (1)The medical authorities: It is not necessarily bad that the hospital provides the out-of-pocket medication items. The hospital could stabilize the operation costs and increase the revenue to achieve sustainable operation. Moreover, it could also reduce the reliance of the financial resource of the health insurance. It could set up the public information platform and the related supporting measures to ensure the rights and benefits of the patients. Also it could appeal and instruct the citizens with the right medication view. (2)Management unit of the hospital: it should get the reasonable balance between the operation performance of the hospital and the maximum benefits of the patients. (3)Physicians: They should primarily concern the benefits of the patients, and perform the informing obligation to make good communication with the patients. In this way, it could avoid the misunderstanding between the physicians and the patients due to the cognitive difference. |
