Huang Ching Chaw, Chung Kuo-Piao, Kuo Nien-Chen, Hung Chia-Ling
Department of Health Care Management, National Taipei College of Nursing, Taipei, Taiwan.
J Formos Med Assoc. 2005 Jul;104(7):468-75.
The introduction of the case-based payment system by the Bureau of National Health Insurance resulted in greatly increased pressure on the health care industry in Taiwan. This study examined the relationship between the coping strategies adopted and the results attained by accredited teaching hospitals and non-teaching regional hospitals when responding to this regulatory change.
A cross-sectional survey was conducted using a structured questionnaire to assess the hospitals' characteristics, and coping strategies at the technical, managerial and institutional levels in response to the case-based payment system, and to compare these strategies with self-evaluation of the effectiveness of these strategies. The questionnaire was sent in early October 2000 to the superintendents of the 129 hospitals that were accredited at the medical center, regional hospital, and district teaching hospital levels in the year 2000. Factor analysis was applied to group the strategies into categories and stepwise regression analysis was used to explore the relationship between the reported coping strategies adopted and their effectiveness as evaluated by participants.
Among the selected hospitals, 89 responded with complete data, a 69% response rate. The following 7 factors were extracted from 30 coping strategies: information and financial analysis; service shifting and unbundling; service integration and quality improvement; service specialization and strengthening; education and training; financial incentives; and claim submission skill. After adjusting for accreditation level or ownership status, 2 main findings were noted. First, hospitals that implemented financial incentives strategies such as holding physicians responsible for all or part of the shortfall between actual claim submissions and actual reimbursements, and reducing or withholding payment to physicians beyond the standard length of stay, tended to increase medical revenue (odds ratio, 1.21). Second, hospitals that implemented service integration and quality improvement strategies, such as implementing a discharge plan, implementing clinical pathways and periodic review of quality indicators, attained higher patient satisfaction rate (odds ratio, 1.40).
This study suggests that hospitals confronting the implementation of a case based-payment system may benefit by adopting financial incentives strategies and by efforts to improve service integration and quality.
台湾地区“国民健康保险局”引入基于病例的支付系统，给台湾医疗行业带来了巨大压力。本研究探讨了教学医院和非教学区域医院在应对这一监管变化时所采用的应对策略与取得的成果之间的关系。
采用结构化问卷进行横断面调查，以评估医院的特征、应对基于病例支付系统时在技术、管理和制度层面的应对策略，并将这些策略与对这些策略有效性的自我评估进行比较。问卷于2000年10月初发送给2000年经医学中心、区域医院和地区教学医院级别认证的129家医院的院长。采用因子分析将策略分类，并使用逐步回归分析探讨所报告的应对策略与参与者评估的策略有效性之间的关系。
在选定的医院中，89家回复了完整数据，回复率为69%。从30种应对策略中提取了以下7个因素：信息与财务分析；服务转移与拆分；服务整合与质量改进；服务专业化与强化；教育与培训；财务激励；以及索赔提交技巧。在调整认证级别或所有权状态后，有两个主要发现。首先，实施财务激励策略的医院，如让医生对实际索赔金额与实际报销金额之间的全部或部分差额负责，以及对超出标准住院天数的医生减少或扣留支付，往往会增加医疗收入（优势比，1.21）。其次，实施服务整合与质量改进策略的医院，如实施出院计划、实施临床路径和定期审查质量指标，患者满意度更高（优势比，1.40）。
本研究表明，面临基于病例支付系统实施的医院，采用财务激励策略以及努力改善服务整合与质量可能会有所益处。
