從實務面來看，總額支付制度（global budget）的施行絕非僅止於管制成本的手段，還必須觀照該管理的制度設計。畢竟制度不但能夠彙集各種資源，同時也成為資源使用的指標，影響行動者間的策略選項。另外，針對政策實施後的監控與評估檢討，也是修正制度與提升品質的反饋歷程。然而，學界與實務界在總額支付制度設計原則的研究卻十分有限，究其原因，重要的是主要集中於制度在實際的應用與效果，缺乏以一套適用的「方法」（methodology）來審視。誠如Elinor Ostrom所言，「政策分析家的工具箱有各式各樣的工具，但還缺乏一種具體明確的集體行動理論。」，共有資源管理的例子到處都有，但是分析家卻沒有很好的在理論上總結他們。他藉由制度分析與經驗實例，衍生出來的「制度設計原則」（Design principles），研究各種共有資源管理的問題：從不同類型的資源系統如灌溉系統、捕魚等自然資源或網路資源、財政預算等、到公共財制度研究等，都已經獲得豐碩的成果。本文的主要目標，就是在既有的理論基礎上，討論應用制度設計原則來進行「總額預算評估」的可能內容，並提出政策建議與後續研究的可能內容提出建議。 本文主要分為：（一）導論（二）文獻回顧與理論基礎（三）研究設計（四）中醫總額支付制度的演變（伍）中醫總額的自主管理（六）結論。希冀對學界或實務界在健保改革評估未來的發展，能有所啟發與助益。 / From the practice, global budget is not just the means to control cost, must also take the design of management into consideration. The institution not only can gather various kinds of resources, but also become the indexes, and influence the tactics among the persons who take action to select. Since a global budget married to fee-for-service payments directly analogous to a common-pool resources, we use a framework of design principles to explore the difference of outcomes of management, and to discuss the policy implications about institutional design and financial Incentives. Sincere as what Elinor Ostrom said, ' the policy analyst's box has many kinds of tools , but still lack a kind of concrete and clear collective action theory. ', example there are resource management in common everywhere, but it is the getting better to summarize they in theory. In addition, the “self-governing institutions” designed by each local medical association must be flexibly adapted to the context in which it is applied. To foster the cooperation among physicians, the medical associations of local level should also play the role to provide the institutional setting for collective participatory decision making. The medical associations of national level ought to change the financial incentives facing the physicians to induce the rational patterns of medical behavior so that the allocate efficiency of medical resource and effectiveness of global- budget management can be improved.

在民主改革之浪潮中，政府的運作已從過往獨斷統治模式走向參與治理的型態。參與式治理的呈現方式包括了審議式民主、以公民為中心之協力公共管理、協力治理等型態。公共政策的制定本應以民意為基礎；因此，引導多元利害關係人至公共政策過程之中，共同制定決策即是參與治理的核心，而決策品質的形成關鍵在於政府如何有效管理、促進多元行動者互動以達成決策的參與過程；然而，回顧文獻發現，決策品質主題卻為學界所忽略。因此，本文從參與式治理觀點出發，以利害關係人之角度切入，選擇全民健保總額制度下的牙醫門診總額支付委員會作為個案，嘗試建構出決策品質評估架構。研究發現，由下至上的利害關係人參與過程不但有助於資訊的蒐集與分享、正確地界定問題，亦促進了利害關係人凝聚共識；同時，平等尊重的溝通態度，增強了政策學習功能；加上公共管理者適時地扮演領導角色，有效解決衝突，促進了決策過程的互動與效率。然而，研究亦顯示支委會決策過程仍有不足之處；參與決策行動者之包容性與代表性仍有改善之空間、決策資訊未達公開透明化、法律規範的模糊不清、以及決策原則標準的缺乏。因此，本文建議應該擴大參與團體類別並考量其行動能力，具體強化多元代表參與之可能；同時，應建立法規和參與機制之適當連結，確立相關法律規範，實踐權責分明的決策過程；最後，更應強調互動討論過程的公共商議精神，促進理性決策的落實。此外，也建議學界未來可著力於相關實務經驗研究，設計更為完善的評估架構，以期對於決策品質面向提供更為豐富完整的論述。 / Under the trend of democratic reform, the way of public administration has changed from despotic to participatory governance. The forms of participatory governance include deliberative democracy, citizen-centered collaborative public management, and collaborative governance. The core of participatory governance is threefold which includes involving multiple stakeholders into policy-making process, to make decisions collectively, and to base public policy making on public opinion. However, after reviewing the literature, it can be found that seldom are there studies of decision-making quality. The quality of decision making lies in effective management of the process; that is, how to encourage and manage different stakeholders’ interactions to make decisions counts a lot. Consequently, this thesis intends to fill the gap by studying the quality of participatory governance and choosing the committee of Dental Global Budget Payment System as a case to establish evaluation framework of decision-making quality based on policy stakeholder participation theory. The research findings reveal several important insights of committee governance. First, on the good side, bottom-up stakeholders’ participation is beneficial not only to the collection and share of policy information to define proper policy questions, but also to the cohesion of stakeholders’ consensus. The way of equal and respectful attitude to communicate accentuates policy-learning function during the process. Furthermore, public managers play a leading role at the right moment to solve a conflict effectively and to promote the efficiency of decision-making interactions. However, there are some defects about the process. There is some room for improvement about the inclusiveness and representativeness of participation groups. Also, the openness of decision-making information is still far from the standard of transparency. The ambiguity of statutes interpretations and the lack of decision-making principles are critical problems to solve as well. Therefore, this study suggests that the government should include even more diverse and complete stakeholders into the decision-making process and help to increase their competence to participate. Also, an effort to closing the gap between regulations and participative mechanism should be made in order to increase the outside-accountability of the process. Thirdly, the spirit of public deliberation should be highlighted during the interactions to increase the rationality of decision-making. Lastly, in order to create a more adequate evaluation framework, this thesis suggests that academia should devote more time to study the issue of public decision-making quality in the era of participatory governance.

所有權結構、支付制度與競爭係影響醫院績效之關鍵因子，本研究援用相關文獻之發現，推論出三項因素對醫院績效之關係，並以我國獨特之總額預算制度為研究對象，蒐集、串連與合併不同來源之資料，實證檢視衝量競爭與所有權結構對醫院營運績效與醫療品質之聯合效果。 台灣於民國91年7月實施醫院總額預算制度後，浮動點值制度之設計為醫院間引入了衝量競爭(即虛假價格競爭)，而結算後之點值則係反映出醫院間衝量競爭後之結果，醫院除了需面對支付點值所致之財務衝擊外，尚須面對自全民健保實行後，備受醫院詬病之核減制度之衝擊，因此，本文首先嘗試估算醫院受到核減與支付點值所致之財務衝擊程度。無論是國外或國內之研究，對於不同所有權結構醫院之績效表現是否有差異性，一直無法獲得一致性之結論，除了納入營運效率之績效指標外，本研究亦採用疾病別與醫院層級別之醫療品質指標來檢視不同所有權結構醫院之績效表現。更以考量核減與支付點值所致之財務衝擊程度，取代目前文獻僅以總額前、後之二元變數，評估財務衝擊程度對營運效率、醫療品質與財務績效之影響。最後，則是檢視總額預算制度下，醫院受到之財務衝擊度是否會縮小不同所有權結構醫院之營運效率與醫療品質表現之差距。 實證研究發現，不同所有權結構醫院之營運效率並未有顯著差異，但不同所有權結構醫院在某些疾病別品質指標(子宮肌瘤切除手術之住院超過7日機率與再入院率)與醫院層級品質指標(院內感染率與淨死亡率)表現上則有差異性；且公立或非營利醫院受到核減與支付點值之財務衝擊高於私立醫院，因此不同所有權結構醫院之行為與績效存有某些差異性。台灣的醫院在總額預算制度下，若受到之財務衝擊程度愈大，其營運效率會變差、醫療品質也受到負面之影響、財團法人醫院之醫務利益率與稅後淨利率也會降低，但現金流量比則會增加，故財務衝擊愈大，醫院之績效愈低。若同時考量財務衝擊度對不同所有權結構醫院之營運效率與醫療品質之聯合效果後，可發現財務衝擊雖然不會縮小公立(或非營利)醫院與私立醫院營運效率之差距，卻縮小公立(或非營利)醫院與私立醫院醫療品質之差距，故以台灣資料可部分支持「不同所有權結構醫院績效差距縮小之因素係競爭力量之崛起」之論點。 / Hospital ownership, payment system and competition are all key drivers to influence hospital performance. This research infer and depict the association of these three drivers from the related literature and empirically examined the effects of fictitious price competition due to the floating point-value system and ownership on hospital operational performance and quality of care by combing and merging different sources of data. Deduction rate of claim and the floating point-value system are the two controversial debates to the payment system. I attempt to estimate hospital financial pressures as precipitated by deduction rate of claim and floating point-value system. To investigate whether for-profit, not-for-profit, and government hospitals differ in operating performance and quality of care, five diagnose-level and two hospital-level quality indicators are selected. Different from prior research, the financial pressure is captured by hospital data instead of a binary variable (pre and post global budget) and I examine the effect of financial pressure on hospital operational efficiency, quality of care and financial performance. Finally, we test whether differences in operational efficiency and quality care among hospitals with different ownership forms will mitigate or narrow, as hospital financial pressure increases. The results show that for-profit, not-for-profit and government hospitals are far more alike than different in operational efficiency, but ownership affects not only the rate of readmission and the rate of the length of stay larger than 7 days of uterine myomectomy, but also the hospital-level quality indicators: the rate of nosocomial infection and hospital mortality rate. I also find higher financial pressure incurred at government or not-for-profit hospitals than for-profits hospitals. Given my findings, we conclude that hospital ownership status affect performance in terms of quality of care and financial pressure from rate of deduction and float point-value system. The study shows that financial pressure adversely affects operational efficiency and quality of care. As not-for proprietary hospital financial pressure increases, the profit margin and net profit ratio will decrease, but the cash flow ratio will increase. Nonetheless, deduction rate of claim and global budget has a negative impact on hospital performance. This research further considers the joint effect of financial pressure on difference between quality of care and efficiency of for-profit hospitals and the other two types. My results indicate that hospital financial pressure mitigates the difference of quality of care between for-profit hospital and not-for profit (or government) hospitals, but does not narrow the difference in quality of care between for-profit hospital and not-for profit (or government) hospitals. This finding partly supports that increased competition should force not-for-profit (or governmental) hospitals to be increasingly similar to their for-profit counterparts.

全民健康保險法自民國83年8月9日公告並自民國84年3月1日施行，此一社會保險制度迄今已成為我國醫療保健系統重要支幹，然而，醫療費用每年約上漲8~10%，致使民國87年3月開始，財務已有入不敷出的情形，因此中央健康保險局（保險人）有一連串開源節流的政策 民國94年2月25日全民健康保險監理委員會第117次會議，委員發言多傾向支持擴大代位求償範圍。此外，全民健保公民共識會議之與會人員，一致認為保險事故如果係可明確歸責於第三人之事由所導致，全民健保之保險人於給付後，應該向第三人代位求償，以符公平正義原則，立法院爰於民國94年5月18日修正全民健康保險法第82條，增訂公共安全事故及重大之交通事故、公害或食品中毒事件為代位求償範圍，修正後條文為：「保險對象因發生保險事故，而對第三人有損害賠償請求權者，本保險之保險人於提供保險給付後，得依下列規定，代位行使損害賠償請求權： 一、汽車交通事故：向強制汽車責任保險保險人請求。 二、公共安全事故：向第三人依法規應強制投保之責任保險保險人請求。 三、其他重大之交通事故、公害或食品中毒事件：第三人已投保責任保險 者，向其保險人請求；未投保者，向第三人請求。 前項第三款所定重大交通事故、公害及食品中毒事件之求償範圍、方式及 程序等事項之辦法，由主管機關定之。」 修法之後，雖然擴大了健保局代位求償範圍，但限制仍多，且此次修法亦未明確釐清健保局在其他領域是否亦有代位求償權 本文首先敘述我國自民國84年正式實施全民健康保險時，尚有盈餘，然而自民國87年起首見保險支出超過保險收入，至民國96年時差額更高達新台幣136億元，除了繼續開發新財源與減少支出外，有無可能利用現有的制度切實實施，消除多數國民有「中央健康保險局將全國人民當成提款機的看法」，以及使實現加害者負其責任之公平正義，故本文針對於全民健康保險法第82條第1項第2款中中央健康保險局對公共安全事故強制投保之責任保險保險人代位權之相關問題加以探討，希望對於日益惡化瀕於破產邊緣之財務有所助益，接者大略簡介我國社會保險制度的演進，包括勞工保險、公務人員保險及其相關保險、退休公務人員保險、公務人員眷屬疾病保險、退休公務人員疾病保險、退休公務人員配偶疾病保險、私立學校教職員保險及其相關保險、農民健康保險與全民健康保險之演進與概況，之後於第三章再藉由歐、美等主要國家保險理論探討保險代位求償權之理論基礎以及人身保險適用代位求償權之理由，復接者討論保險代位求償權之性質、民法上行使代位權之限制、保險法上保險人代位權之性質與全民健康保險保險人之代位求償權；於第四章則討論目前我國中央與地方法規中有哪些場所或行業係屬須強制投保公共意外責任保險以及公共安全事故中全民健康保險保險人代位求償權之構成要件；於第五章則討論全民健康保險保險人可代位求償之金額尚須受到中央健康保險局實際所支出之醫療給付與強制責任保險之保險金額限制；於第六章則討論保險對象對於中央健康保險局代位求償權之保全有協助義務以及節妨礙代位之事由與代位求償權之消滅時效；第七章則是探討中央健康保險局行使代位求償權應注意事項；最後於第八章則是結論與建議。