從世界醫藥分業發展看臺灣基層西醫診所門內藥局發展與調整之研究

Abstract

在醫療院所的健保申請給付中，門診的藥品調劑給付金額在基層西醫診所的營收當中佔有相當程度的重要性，然而歷年基層西醫診所開設門內藥局仍維持在60%~70%的高比例，並且探討基層西醫診所門內藥局的發展研究文獻有限，因此如何健全醫藥分業的制度政策即成為一項重要課題。本研究目的將從綜括世界醫藥分業制度發展，探討臺灣在全民健保政策實施後，以新制度主義理論為基礎，針對基層西醫診所開設門內藥局進行分析、探討與建議其發展和調適。研究方法的使用上，先透過「文獻分析法」與「比較與歸納法」進行質性分析，建立世界主要國家醫藥分業制度之比較，再透過全民健康保險資料庫中自西元1999年到2010年的完整12年次級統計資料，針對基層西醫診所開設門內藥局的現象進行趨勢分析、卡方檢定與多元邏輯斯迴歸等量化統計分析。研究結果顯示，門內藥局的趨勢變化中，西元2002與2006兩年異於其他年度有特別的波動變化，說明管制者制度政策的調整會影響受管制者的行為與決策。並且除了醫師性別外，醫師年齡、醫師專科別、月門診量、每件醫療費用、每件門診處方簽藥品費用、診所密度、地區分局別等七個研究變項，均與開設門內藥局的關聯性具顯著性。其中，女性醫師，年齡介於41~60歲，耳鼻喉科、內科、小兒科、皮膚科以及復健科等專科診所有較大傾向開設門內藥局，並且隨著月門診量、每件醫療費用、每件門診處方簽藥品費用的增加，基層西醫診所較傾向開設門內藥局，此說明了「利潤收入」是開設門內藥局一項重要因素。未來可參照日本政府，提高基層西醫診所合理的診察給付費用，調整健保給付的分配並差異化，同時汲取各國經驗，全面實施六年制藥學專業教育以提升藥師一致專業度，並將現階段醫師法第14條與藥事法第102條經過研議溝通後進行整合修法，使醫藥雙方針對調劑權歸屬的紛爭消失，臺灣實施完全醫藥分業目標便可期待。

In comparison to the reimbursement of National Health Insurance (NHI) in all medical institutions in Taiwan, the reimbursed amount of drug dispensing in outpatient treatment played an important role in the total revenue of clinics. Moreover, the proportion of the clinic having pharmacy inside in the past decade is still high. However, the researches in discussing the development of physician-owned pharmacy in clinic were limited. The purpose of this study was based on the theory of the New Institutionalism to analyze the policies of separation of drug prescribing and dispensing in different countries and to explore the development and adjustment of physician-owned pharmacy in clinic in Taiwan. The qualitative methods, including documentary and comparative analysis, and the quantitative methods, including trend ayalysis, pearson’s chi-square test, and multinominal logistic regression model, were conducted in this study. In the quantitative method, the analytical data was obtained from the NHI research database for a total of 12 years, from 1999 to 2010. In conclusion, the study found that the variety in year 2000 and 2006 were different from others. This represented the policy changed by the government controller would affect behaviors of the controlled parties. Except the gender of physician, to set up physician-owned pharmacy in clinic would have significant correlation with factors of age, specialty of physician, monthly service amount, diagnostic treatment fee per case, drug dispensing fee per case, clinic density, and clinic location. In addition, such factors as female, aged 41 to 60, specializing in ENT, internal medicine, pediatrics, dermatology, or rehabilitation, and such environmental factors as the increasing of monthly service amount, diagnostic treatment fee per case, and drug dispensing fee per case would make physicians more inclined to set up pharmacy in clinic while indicating profit was an important factor. The study suggested that Taiwan authority could learn from the experience of Japanese government to adjust the reimbursement of NHI. Moreover, to upgrade comprehensively the profession of pharmacists by practicing 6-year pharmacy education for a Pharm. D. degree and to integrate to eliminate the disputed law concerning the right of drug dispensing, the complete separation of drug prescribing and dispensing in Taiwan could be expected.