契約式物理治療之營運模式和策略的探討

Abstract

醫療保健是全民重視的議題，醫療照護日益複雜、管理醫療日興，即便是公立醫院也非常重視各科（部）的財務平衡。在我國醫院體制，物理治療多定位於復健科（部），受限於病人只能來自復健科（部），可服務的族群減少，加上治療收費低廉、成本單位無與醫師劃分，營運大不易。近年來不少私立之區域醫院將物理或復健治療獨立於復健科（部）之外，增加各科轉介病人的服務，除了方便民眾，績效管理也是部分原因。 目前在國內並無正式契約式物理治療的營運模式，急性期後（出院後）的照護也多侷限於病人親至門診接受復健的模式。老年人口逐年增加，如何加強急性期後（出院後）老年病友的生活功能以及對慢性病人急性期後的健康促進、改善服務的連續性，以增進品質，也是重要議題。本研究透過文獻回顧和專家訪談，簡介契約式物理治療或復健的營運模式，並彙整訪談專家的成功經驗，同時探討此一模式在我國的可行性和策略計畫。 在美國經營契約式物理治療或復健因有各科照會轉介，且不論是政府或私人保險都重視且支付急性期後（出院後）的照護，是關鍵的成功因素。我國醫院對區域內有上述居家復健需求的病人或可採行契約式物理治療或復健的方式，依交易成本和資源基礎理論選擇醫院自理或院外組織承包或混合方式。 策略計畫建議如下： （1） 多元發展，整合現有衛生、社福資源，尋求私人保險公司合作機會，重視居家照護。 （2） 加強教育訓練、建立口碑、形成優勢。 （3） 居家照護採作業基礎成本制，並注意經營管理系統。 （4） 以跨專業的復健治療為經營號召，建立市場規模，降低人力和作業成本。 （5） 遊說健保局增加居家治療的項目，以有效利用醫院之醫療資源。

Healthcare is one of the most important public policy issues today. The healthcare system gets more and more complicated with an extensive network of healthcare providers. Hospital administrators find their institutions are experiencing a variety of financial, regulatory, and reimbursement-related challenges that are putting increased pressures on their operations. Cutting down the expenditure without influencing the quality of care becomes the important policy of hospital executives and department administrators. Department of Physical Medicine and Rehabilitation in hospital is in great need of creative ways to cut costs and restructure its businesses. There are several factors contributing to the poor financial status of the department, such as limited patient source, low charge for the treatment. For the convenience of patients and the purpose of performance management, many Physical Therapy Sections in private owned regional hospitals have become an independent division to provide direct care for referred patients from many other practitioners of medical specialties. There is no official operational model of contract rehabilitation providers in the Taiwan healthcare delivery system. Patients after discharge often have to go the outpatient department to get physical therapy or rehabilitation services which is not convenient and costly for the elderly and the disabled. Facing the growing elderly population and acute on chronic conditions admitted to hospital in Taiwan, the post-acute care should be emphasized. To survive in the turbulent times, hospital administrators and physical therapy profession practitioners should come up with innovative strategic planning or business model to develop a sustainable service of their operations. In this research, literature review and in-depth interviews with rehabilitation contract providers are used to introduce Contract Physical Therapy Practice and key success factors of the interviewed contract rehabilitation providers, and to investigate the feasibility in Taiwan and its strategic plan. The postoperative patients from departments of orthopedics and cardiac surgery are main patients source for contract physical therapy in the States and the reimbursement from public or private insurance are operating fine. These may be the key success factors for the practice model. The research results suggested that the contract design of rehabilitation services in Taiwan could be made by hospital, contracting a staffing agency or using a mixed model based on the transaction cost and the resources available. Strategic planning is suggested as the followings: (1) Serve in many capacities by integrating limited resources and seeking cooperative opportunities with private insurance companies. Emphasize on home health care practice. (2) Develop a partnership model between hospitals and/or government. High standards of quality and good outcomes needed to support new niches in physical therapy practice. (3) Apply activity-based costing and management control systems for home health care practice. (4) Run multidisciplinary rehabilitation services. Establish the market scale to reduce cost of human resources and operation. (5) Convince Bureau of National Health Insurance (NHI) to include post-acute Home Health Care in NHI program to achieve the greatest efficiency of hospital’s medical resources.