醫師對於論質計酬支付制度的認知及態度研究－以糖尿病醫療給付改善方案為例

Abstract

背景與目的：台灣於2001年推出五大疾病論質計酬，其中糖尿病論質計酬於2007年開始依醫療院所照護病人結果面指標作為獎勵條件，跨出真正論「質」的第一步。國外已有許多調查醫師對於論質計酬的認知與態度的研究，用以評估計畫的成效及了解現況，然而國內的研究仍付之闕如。因此本研究將針對參與糖尿病論質計酬的醫師進行調查，了解其對於論質計酬的態度，並探討其與醫師認知、個人特質及醫療院所特質的相關性。 研究方法：本研究引用國外學者Meterko等人發展之「Provider Attitudes toward Incentives」問卷，並依研究目的增加題項。透過三位專家學者進行效度檢測及八位醫師進行前測，對部分題項進行修擬後完成定稿。本研究為橫斷性研究，對象為全台參與糖尿病醫療給付改善方案院所之醫師，以立意取樣的方式進行。問卷發放期間為2009年4月24日至6月3日，共發放585份問卷，回收有效問卷207份，有效問卷回收率為35.38%。 研究結果：研究結果顯示醫師對於論質計酬支付制度的理念大多持有正面的看法，有83.6%的醫師認為當醫師達到較好的照護品質時，健保局應給予財務獎勵，75.4%的醫師相信給予財務獎勵是增進醫療照護品質的有效方法，並有71%的醫師認為財務獎勵相較於非財務獎勵，為較佳的獎勵方式。多數的醫師認同糖尿病論質計酬的「預期效果」，但對於「組織支持」的認同較低，特別是在財務支持的部份，有40.6%的醫師不同意「糖尿病醫療給付改善方案」給付的金額，足以補償達到品質指標獎勵目標。本研究結果亦得到醫師個人特質中的最高學歷、機構特質與醫師對於論質計酬的認知會影響醫師對於論質計酬的態度。其中當醫師對於國內論質計酬的自評了解越高、對論質計酬的財務分配越了解，對於論質計酬的態度越呈正向關係；此外，機構中領導者的鼓勵也能提升醫師對於論質計酬正面的態度。 建議：對於未來研究的建議包括：可增加質性的部份，補強機構特質在執行論質計酬時的差異與影響，以及了解院所對於財務獎勵的分配方式；探討態度與行為的關連；可從護理人員、營養師、衛教師，甚至病患的角度來加以分析比較；將研究對象擴大到其他論質計酬方案進行探究。

Background and Objectives: In 2001, the pay-for-performance programs was applied in 5 main diseases in Taiwan. Among them, the program for diabetes mellitus firstly adopted clinical outcome indicators as the reward basic. That was the real first step in rewarding the “performance.” Studies from foreign countries have investigated physicians’ knowledge and attitudes toward the pay-for-performance system in order to understand the implementation conditions and evaluate its effectiveness. However, local studies related to this issue are limited. This study aimed at understanding the knowledge and attitudes toward the pay-for-performance among physicians who participated in the diabetes mellitus pay-for-performance program. In addition, the relationships among physician’s attitudes, knowledge, personal characteristics, and characteristics of healthcare institutions were examined. Methods: The investigation instrument in this study was based on the “Provider Attitudes toward Incentives” questionnaire developed by Meterko and his colleagues. Additional questions were added to fit the research purposes. According to the validity test by three experts and a pilot test for 8 physicians, several questions were revised. This was a cross-sectional study focusing on physicians participated in the diabetes mellitus pay-for-performance program in Taiwan. A purposive sampling method was adopted. 585 questionnaires were distributed between April 24th and June 3rd, 2009 and 207 valid questionnaires were returned. The valid response rate was 35.38%. Results: Study results showed that most of the physicians held a positive attitude toward the pay-for-performance mechanism. 83.6% of the physicians thought that the Bureau of National Health Insurance should provide financial incentives to a physician when his/ her services achieved a better quality. 75.4% of the physicians believed that the financial incentive was an effective approach to improving quality of health care. 71% of the physicians suggested that financial incentives were better than non-financial incentives. Most of the physicians applauded the “anticipated outcome” under the diabetes mellitus pay-for-performance program, while they approved with the “organizational support” less. This situation was especially significant with respect to the “financial support”, that 40.6% of the physicians did not think the amount of reimbursement under the “Medical Benefit Improvement Project in Diabetes Mellitus” could compensate the effort they spent to fulfill the goal. This study also found that physician’s education level, characteristics of the healthcare institution, and physician’s knowledge of the program could impact the physician’s attitudes toward the program. Through the self-administered questionnaires, those who understood the program and the financial distribution more were more likely to have a positive attitude toward the pay-for-performance program. Furthermore, the encouragement from the chief of an institution could contribute to physician’s positive attitudes toward the program. Suggestions: Suggestions for future study include: using the qualitative method to strengthen the healthcare institution aspect to understand its impact on the implementation of the pay-for-performance program and the distribution of financial incentives within an institution; exploring the relationship between attitudes and behavior; broaden the investigation targets to include nurses, nutrition consultants, health education practitioners, and even patients; studying the effect of this program in other diseases.