分級醫療與就醫自由： 醫院組織、醫師及就醫民眾之意向與行為研究

Abstract

健保施行二十七年來在民眾就醫自由，大型醫院門診逐年成長，地區醫院數量減少，診所門診占比減少，未曾施行健保法第43、44條部分負擔定率及家庭責任醫師制。雖曾多次調漲民眾部分負擔，但是分級醫療效果不顯著。近五年來，台灣衛生主管單位推動許多分級醫療相關政策，醫事司2017年開始推行第八期醫療網重新定位健康照護體系，健保署也從2018年開始推動醫學中心以及區域醫院門診減量與區域整合計畫，許多醫院開始發展分級醫療策略聯盟。對於發展全民健康覆蓋照護體系的高度經濟發展國家來說，分級醫療既是健康照護體系的轉診秩序，也是民眾就醫時所遵循的義務。在國家推動分級醫療策略之際，本研究旨在進行針對醫院組織、醫師以及就醫民眾對分級醫療意向與行為的調查。 研究目的：調查醫院組織因應國家分級醫療政策所採取的分級轉診策略與組織變革(體系合作、轉診流程、內部規範、財務誘因)；探討醫師分級醫療意向(就醫態度、主觀規範與知覺控制)與分級轉診行為的關聯性；分析民眾分級醫療意向與分級就醫行為的關聯性，並與上述醫師族群的調查結果進行比較。 研究方法：本研究共分三部分，「研究一」為醫院組織研究，研究資料為2020年台北醫師公會主導的台北區醫療網分級醫療計畫推動研究調查，包含各醫院的分級轉診策略及開放式政策建議，共有50家醫院填答；「研究二」為醫師調查，以滾雪球方式進行全國醫師對分級醫療意向與轉診行為之研究，共有834位醫師填答；「研究三」為就醫民眾調查，依照全國全年門診人次比例，採配額抽樣，邀請26家醫療院所參加，共有1135位民眾回覆。醫師及就醫民眾的分級醫療意向測量，量表首先經過專家效度檢定，再以SPSS 25軟體進行探索性因素分析及AMOS 26進行驗證性因素分析，將分級醫療意向分為三個構面因素：「就醫自由限制」、「分級轉診規範」、「經濟行為控制」，合計13個題項。最後再以SPSS 25進行卡方檢定、羅吉斯迴歸分析上述三個分級醫療意向構面因素、轉診(或就醫行為)與其他變項的關聯性。 研究結果： 一、台北區12個分級醫療策略聯盟規模不同，均採多元開放的院際合作模式。雖分級醫療政策六大措施實施兩年後，主責醫院門診轉入占比提升，但簽約合作院所轉入占比仍不到五成。研究亦發現醫院組織策略無公私立醫院的差別，主責醫院和參與醫院對於實施分級醫療的障礙因素其中兩項看法不同：「限制民眾自由就醫」(p=0.039)和「提高未經轉診民眾的分級負擔差異」(p=0.017)。至2020年中為止，台北區醫療院所尚未形成類似美國的權責健康照護組織的有機連結。 二、研究二的醫師調查顯示，醫師門診轉出行為和分級醫療意向無關(「自由就醫限制」、「分級轉診規範」或是「經濟行為控制」)。家庭醫學科醫師明顯較其他專科醫師支持就醫自由的限制。 三、研究三的民眾調查發現北北基、除了分級轉診規範高分者，比較有意願在社區就醫，其餘民眾就醫行為(門診次數高低、最常就醫地點、社區就醫意願)和分級醫療行為意向(「自由就醫限制」、「分級轉診規範」或是「經濟行為控制」分數)也沒有關聯性。同時，民眾於「分級轉診規範」意見分數及分布，和醫師類似。 研究貢獻：本研究呈現在台灣無明確分級轉診規範及民眾就醫自由條件下，當前分級醫療策略聯盟運作的現況、醫師及就醫民眾對於分級醫療意向與行為的關聯性。研究發現台灣醫師與就醫民眾對於「分級轉診規範」與「經濟行為控制觀點」相近，可以提供未來制定分級醫療政策的參考。 研究限制：本研究醫院調查對象限縮於台北醫療區，雖醫師與病人調查對象為全國，但受限於樣本抽樣方式，研究結果僅反映填答醫院、填答醫師、抽樣醫療院所的就醫民眾對於分級醫療意向(態度、規範、行為控制)與就醫行為，外推性受限。

Introduction：In recent years, Taiwan''s health administrative have promoted many policies related to hierarchy of medical care. In 2017, the Medical Affairs Bureau of the Ministry of Health and Welfare has implemented the eighth phase of the medical network to re-establish the healthcare system. The National Health Insurance Administration has also been promoting the reduction of medical center and regional hospital outpatient services and regional integration plans since 2018. Many hospitals have begun to develop medical alliances for the level of care. Despite it has raised some small-scaled patients’ out-of-pocket for several times, Taiwan''s National Health Insurance system has neither implemented the critical part of cost-sharing strategies with proportion nor the family physician systems specified in Articles 43 and 44 of the National Health Insurance Act. In Consequence of patients'' freedom to choose, larger proportion of outpatient services in medical centers, fewer numbers of regional hospitals, and smaller proportion of community clinic were seen year by year. However, almost every country with highly-developed economics has their referral system with patients’ obligation to initially visit outpatient in the community health care facilities. Purpose： This study aims to explore the intentions and behaviors of medical institutions, physicians, and patients regarding hierarchical health care system. This research focuses on analyzing the organizational changes within hospitals that comply with national referral care policies. It also explores the correlation between physicians'' and patients'' intentions (attitude towards seeking medical treatment, subjective norms, and perceived control) and referral-making or doctor-seeking behavior, and also evaluates the effectiveness of establishing the referral system for level of care. The study hypothesizes that the role of the medical alliance (responsible hospital or participating hospitals) and the character of medical institutions (public hospital or private hospital) have different evaluation on the effectiveness of referral system, and there is a correlation between physicians'' or patients'' intentions and referral-making or doctor-seeking behaviors. Material and Methods： The study is divided into three parts: hospital organization research, physician survey, and patient survey. The hospital research was conducted by Taipei Medical Association in 2020, while 50 hospitals responded out of 107 hospitals. It includes the institutional strategies, referral statistics, and the policy evaluation. The physician survey collected 834 national -wide physicians by snow-ball sampling. A total of 1135 Patients were collected by quota sampling from 17 hospitals and local clinics from acquaintance. The above two individual studies were investigated by structuralized questionnaire, while the common scale for measuring the intention toward achieving level of care was validated by experts, explanatory factor analysis and confirmatory factor analysis. The statistics were made by SPSS 25 and AMOS 26, while frequency tables, Fisher exact tests, Chi-square tests, and logistic regressions were applied. Results： First of all, medical alliances around the area within Taipei medical district worked differently from the accountable care organizations (ACO) in the US. The proportion of outpatients from referral has been increased, but only half of them referred within the organization. The operating mechanism is based on open and diverse relationship. Normative regulations toward medical referral spread internally and externally. However, not every main hospital provides financial incentives for physicians’ referrals. The main hospitals and participating hospitals have different opinions on the barriers to implementing hierarchical health care system, such as "restricting people''s freedom to doctor-seeking and hospital shopping" (p=0.039) and "increasing the financial disparity for non-referral patients" (p=0.017). Secondly, the physician survey shows that the referral behavior of physicians in outpatient clinics is not related to their intention towards graded medical care (freedom of seeking medical treatment, referral norms, or economic behavior control). Family physicians are more supportive of restrictions on freedom to choose, and physicians generally have higher scores for their intention towards graded medical care compared to the patients. Thirdly, the patient survey found that apart from those with low scores in referral norms, there is no correlation between doctor-seeking behavior (frequency of outpatient visits, the most common healthcare location, willingness for community care) and intention towards hierarchical medical care (freedom of seeking medical treatment, referral norms, or economic behavior control). At the same time, the patients’ scores and distribution of opinions on referral norms are similar to those of physicians. Research contribution: This study analyses the current situation of medical alliance, physicians, and patients in Taiwan under a high degree of freedom in seeking medical treatment and without clear referral norms. It provides insights into healthcare policy-making and contributes to the promotion of equitable healthcare access if hierarchical medical care was needed to be built. The findings of this study could provide insights into the effectiveness of graded medical care policies in Taiwan. By analysing the intentions and behaviors of medical institutions, physicians, and patients, the study could identify potential barriers and facilitators to the implementation of hierarchical medical care system. This could inform future policy development and implementation strategies. Limitations: This study was limited to the hospitals in Taipei medical district, while the participants included physicians and patients were collated from across the country. However, due to the sampling method, the research results only reflect the attitudes, norms, and behavioral control regarding hierarchical medical care system and healthcare-seeking behavior of the participating hospitals, physicians, and sampled individuals. The generalizability of the findings is limited. The study highlights the similarities and differences in perspectives on graded medical care and healthcare-seeking freedom among hospital organizations, physicians, and the general public under the current public nature of the healthcare system and freedom of seeking medical treatment.