市場暴露對公立醫院營運績效之影響

Abstract

背景與目的：環顧全球，許多國家的公立醫院多年來普遍存在無效率、低生產力以及對病人無責任感、等候名單過長、市場競爭性不足等問題，這些國家為了化解此一困境，自80年代起，以解決公立醫院根本上之結構性問題著手，導入市場化組織改革。近年來，台灣公立醫院亦有著與國外公立醫院相同的營運困境，而政府財政日益困難，採取降低補助款之方式，增加醫院的市場暴露程度，期望提升公立醫院的營運自足率，減少對政府補助的依賴。本研究欲藉由長期資料分析，探討增加公立醫院之市場暴露程度是否能提升醫院生產效率。 材料與方法：研究對象為國內公立醫院總病床數在100床以上之急性綜合醫院，包括6家台北市立醫院、3家高雄市立醫院、2家縣立醫院、21家衛生署管轄之署立醫院、2家教育部管轄之大學醫學院附設醫院、行政院國軍退除役官兵輔導委員會管轄之3家榮民總醫院以及10家榮民醫院以民國87到91年五年之資料進行長期性分析。利用各院投入、產出資料，並對各公立醫院各年度住院服務進行病例嚴重度（case mix index）校正，再藉由資料包絡分析法（data envelopment analysis, DEA）計算公立醫院技術效率值後，利用結構方程模式（structural equation modeling, SEM），探討公立醫院市場暴露程度與其生產技術效率之相關。 結果：在兩項評估市場暴露程度的指標中，第一項指標市場收入與補助款之比率的變化趨勢與效率值的變化趨勢呈現的因果關係為正向且具統計之顯著性。而後再分析第二項指標補助款的變化趨勢與效率值的變化趨勢，同樣進行平行成長曲線模式作比較，發現補助款變化後之百分比趨勢與效率值的變化趨勢在因果關係上呈現負向且也具統計之顯著性。 結論：本研究透過兩項代表市場暴露程度的指標支持了理論點，即增加公立醫院的市場暴露程度會顯著提升公立醫院之生產效率值，此亦肯定了台灣對公立醫院所實行市場化組織改革政策與其目的相符。

Objective：Around the globe, there are common problems in public hospitals in many countries for years, including inefficiency, low productivity, slow response to customer requirements, long waiting list, and insufficient market competition. To solve these deficiencies, since 80’s many countries have introduced market organizational reform and aimed at the fundamental problems of public hospitals. Recently, the public hospitals in Taiwan have faced similar operating difficulties shared by the globe. Due to the escalation of financial deficit, the government tried to decrease governmental subsidy to public hospitals by increasing their market exposure. This study examined the effects of market exposure on the performance of the public hospitals in Taiwan. Data and methods：The sample of the study were public general hospitals with more than one hundred beds in Taiwan, consisting of six Taipei municipal hospitals, three Kaohsiung municipal hospitals, two Taipei county hospitals, twenty-one DOH owned hospitals, two university hospitals, three veterans medical centers and ten veterans hospitals. Data were collected from 1998 to 2002. The efficiency scores were first measured by data envelopment analysis. Inputs considered in efficiency analysis were physicians, medical persons, total beds, and outputs were inpatient discharges and outpatient visits, both adjusted by severity. SEM then was employed to analyze the effect of market exposure on production efficiency. Principal findings：The market exposure trend has a positive and statistically significant effect on hospital efficiency. Subsidy trend however has a negative and statistically significant relation with hospital efficiency. Conclusion：This study supports the theoretical perspective of increasing the degree of market exposure to improve efficiency in market organizational reform by the government. The increase in the production efficiency of Taiwan’s public hospitals also affirms the right track reform.