生技醫療服務公司之成長策略分析 – 以佳醫集團為例 / ABSTRACT Taiwan government in March of 2009 announced that six emerging industries have been specially selected for intensive development. They were biotechnology, medical care, green energy, quality agriculture, cultural creative and tourism. ”Biotechnology Takeoff Package” was firstly launched on March 26. This package is expected to bring Taiwan’s biotechnology and medical service environment to international standards, and rapidly making it “trillion dollar industry.” However, resource is limited. Compared to other technology advanced countries such as America and Japan, Taiwan owns less population, smaller size economy and rather limited nature resources. How should Taiwan develop its specially selected industries? What would be the best strategy for Companies interested in entering these selected industries? The aim of this study is to explore the growth strategy of medical services related companies and to conclude with some useful suggestions for Companies interested in entering biotechnology and medical service industry. This paper uses a case to observe the growth path of medical service industry. The author collected the data relating to the case company from its annual reports and various periodicals, and then applied theories of growth aiming to conclude the successful strategies made by the company. The current study chooses the largest dialysis treatment services company in Taiwan, the Excelsior Health Care Group, as the case study subject. During its twenty-one-year development history, the Group has been growing through vertical and horizontal integration and entering joint ventures with diversified businesses, such as cosmetics medicine, long-term health care, pharmaceutical logistics services and various clinical services such as dental and eye clinical services. The growth strategy of the group can be decrypted in the models of “Resource Based View”, “Core Competence Theory” and “The Boston Matrix.” This research concludes that the company has made several successful strategies including (1) using financial leverage to gain sufficient funding to sustain its investment in new businesses, (2) basing its original core competence and development related to other core competencies, (3) extensively entering into joint ventures with partners when exploring new business.

目前台灣中醫以門診為主，雖有部分醫院經營住院部門，但由於現階段全民健保尚未將「中醫住院」納入為給付範圍，導致中醫住院的病患必須全部自費，所以利用率偏低，因此中醫的主要業務仍在診所部分。1995年至2010年的統計數據發現，中醫診所有急遽增加的趨勢，加上中醫師人口成長幅度過快及中藥材成本上升，使中醫診所面臨激烈競爭，而如何有效提升醫療服務品質與病患回診意願，將是診所經營者當務之急。 　　本研究參考蔡文正等人(2008）運用PZB(Parasuraman, Zeithaml and Berry）SVERQUAL量表所建立之中醫醫療服務品質評估指標，衡量模式的五個構面，分別是有形性、可靠性、回應性、保證性及關懷性，並根據回診意願之相關文獻，發展出病患回診意願之評估指標，藉由問卷調查，以新北市五家中醫診所病患為研究對象，探討病患對於中醫診所提供之醫療服務品質的重視情形、實際接受服務後的滿度程度及回診意願的影響。 　　研究結果顯示中醫診所病患對於醫療服務品質的實際感受較本身所期望之服務有落差，不同特性之病患對於醫療服務品質的重視程度與滿意程度、回診意願也有差異情形；由相關分析與迴歸分析得知，醫療服務品質重視程度和滿意程度，與回診意願皆有顯著的正相關存在，且以醫療服務品質的「回應性」、「保證性」及「關懷性」三個層面的滿意程度，對「回診意願」有較高預測力。故未來中醫診所針對回診意願之提升，應以此為主要策略目標；同時，對於滿意程度較高之指標應強化、保持，在增進病患回診意願上必有所助益，俾使民眾擁有更優質之醫療環境。

研究動機與問題：本研究最主要的目的希望能夠將最易被大家忽略的健保醫療檢驗資源使用問題，從實務面上探討，並指認出有效使用醫療檢驗資源的關鍵因素，針對這些因素與措施進行評估，歸納出具體明確可行的方向，提供主管機關做為費用管控的參考，為我國健保永續經營貢獻一份力量。 本研究根據研究動機與目的，設定三個研究問題：1.影響醫師有效的使用醫療檢驗資源的因素有哪些？2.藉由桃園縣執業醫師的看法了解有效使用醫療檢驗資源關鍵因素為何？3.不同執業院所、服務科別、職別的醫師對有效的使用醫療檢驗資源看法是否有差異？ 研究資料與方法：以文獻回顧法、問卷調查法、深度訪談法蒐集資料及驗證資料；研究過程分三個階段進行，第一階段為背景資料與文獻資料的蒐集，瞭解醫療檢驗資源使用現況與問題，並透過訪談實務界菁英驗證文獻與補充資料不足；第二階段依文獻分析與彙整內容設計問卷與訪談大綱；第三階段將回收的問卷編碼、整理後以Excel/2003版與SPSS for window12.0版套裝軟體進行資料分析；深度訪談資料透過內容分析法予以歸納整理分析。獲得研究答案，達成研究目的。 研究結果與建議：量化研究部分，本研究共分送488份問卷，回收318份，回收率為65.1％。並以卡方檢定樣本與母群體並無差異，可代表母群體。質化研究部分，深度訪談三位年資10年以上實務界菁英，建構本研究實務上的概念。歸納研究結果：醫療檢驗資源有效使用的關鍵影響因素有「醫療風險」、「病人就醫行為」與「照護之連續性」3項。根據研究結果，為有效使用醫療檢驗資源，必需減少醫療風險、規範病人就醫行為與進行照護流程改造。 / Background:The purpose of this research is to find out the influencing factors related to the usage of resources for medical examinations under the Taiwanese National Health Insurance (NHI). From the practical point of view, this research focuses on, the first, defining the efficient use of medical test and then finding out the critical factors effecting the efficient usage from medial practitioners’ viewpoints in Taoyuan County, Taiwan. It is expected to provide advisory values to improve the global budget system of NHI. Research Questions: 1.What are the factors influencing doctors to utilize medical examination efficiently? 2.What are the certified medical doctors of Taoyuan County thinking about these factors? 3.Concerning the above factors, do there exist systematic differences among medical doctors from different hospitals, rank of medical doctors and fields of profession? Methods: In this study, author utilizes literature review, questionnaires, and in-depth interview. The survey was divided into three stages. First, related information was collected to clarify the problems of medical examination usage in present situation from both interviewing medical practitioners and literature review. In the 2nd stage, a general questionnaire was designed to administrate to selected medical doctors in Taoyuan County in mid-2008. The last stage was data coding and analyzing by using Excel/2003 and SPSS for Windows. The return rate was 65% (318/488) and there is no difference between population and sample after consistency test. Results and Suggestions The results show that the key factors of efficient medical examination usage are medical risk-aversion of doctors, clinical shopping of patients, and the need to medical care continuity. These exist a greater viewpoint differences between different level of hospital than different ranks or specialties of doctors. These results will lead the author to suggest that the Bureau of NHI needs to promote adequate mediation mechanism to reduce medical risk, to promote inter-hospital patient information sharing system, and to improve the logistic of continuity care.

因國人健康意識改變，就醫動機除了疾病之診斷治療之外，亦要求醫療活動之安全與品質。現行醫療訴訟實務，無論採用契約責任或侵權責任為請求權基礎，多以醫事人員是否有過失行為為主要爭點；然而，造成醫療損害的原因包括管理過失及人為過失，而醫療錯誤常發生在人與物的介面之中，此種訴訟方式將使醫療錯誤隱藏於醫事人員過失背後，無法呈現出醫療損害發生原因之全貌，亦無法對醫療品質改善及病人安全提升有所助益。本文以維護病人安全及提升醫療品質為目標，以醫院病人關係為基礎，重新定義醫院醫療服務及其內容，並建構醫院醫療服務之民事責任。 醫院之醫療服務係指「病人就醫過程中，醫院為診治病人所提供之一切專業醫療服務。」此定義涵括病人就醫過程中，所有需要專門醫事人員執行之醫療行為，及相關輔助之醫療軟硬體。 在醫院病人之醫療契約方面，病人締約目的為「以『專業』『安全』之醫療照護體系，達到控制或降低疾病可能風險的目標」，醫院依債務本旨應以「『專業』『安全』之醫療照護體系」為給付。醫院若違反其契約上給付義務，致病人受損害者，將可構成債務不履行責任。 在醫院醫療服務之侵權責任方面，無論僱用人侵權責任採推定過失或無過失責任模式，於醫療實務之適用上皆有許多缺點，而且無法對病人安全及醫療品質有所助益，我國應參考德國組織義務理論及美國醫院組織責任，建立醫院本身義務之理論基礎與具體內容，使醫院因醫療錯誤造成病人損害時，能獨立負起侵權責任。而違反保護他人法律之侵權責任因涉及法律認定之解釋問題、法律體系混淆及法律經濟因素，於醫療服務之適用仍有待研究。 醫院醫療服務是否能適用危險責任，應依立法目的、服務本質、分散風險可能性、舉證困難等因素，決定其適用可能性。鑑於侵權行為之個人責任原則無法提升醫療品質，病人亦無法得到實質賠償，美國學界開始提倡醫療企業責任，以醫院作為醫療錯誤的唯一賠償責任人，使醫院致力於醫療錯誤之防免，達到維護病人安全及提升醫療品質之效果。考量我國目前醫療環境，在醫院企業化經營下，無過失責任於醫院醫療服務之適用應有重新審視之空間，以充實我國醫療糾紛民事損害賠償法制。實務應思考何謂「醫療服務提供欠缺安全性」的概念，以促進病人安全與提升醫療品質。

本研究以大量客製化的方式，在兼顧成本及客製化的雙重需求下，歸納出醫療產業可採取九種大量客製化模式，平衡醫療供需及促進醫療創新。如：〝共享〞─相同的元件，可以被橫跨使用在不同的產品，達到範疇經濟。〝替換〞─不同的元件可以使用在相同的基礎元件上。〝裁切〞─元件可以依客戶的需求做裁減。〝混搭〞─混搭不同的元件形成一個獨特的產品。〝平台化〞─建立一個標準架構，使其可以承載不同的元件。〝介面化〞─允許不同的元件做任意的組合。〝移除〞─移除指定元素，進而產生客製化的產品或服務。〝置入〞─依顧客的需求對於既有的標準產品或服務，進行置入。〝取代〞以置入的方式取代另一被移除元素。 此外，本研究涵蓋非醫療產業(硬體、軟體及服務業)與醫療產業(醫療服務及醫療生技)的跨產業分析比較，一方面可得知醫療服務及醫療生技如何進行大量客製化，另一方面借鏡觀形，了解醫療服務及醫療生技仍有待改進的地方。 最後，為了方便企業找出適合的大量客製化模式，本研究共整理醫療服務及醫療生技的12種大量客製化應用方式，而且這十二種應用方式，並非互相排斥，可混合運用於企業的營運模式之中。

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全球面臨人口老化與人口不斷成長的壓力下，對於醫療服務的需求不斷提升。醫療服務領域中常以資料探勘「關聯規則」分析，挖掘隱藏在龐大的醫學資料庫中的知識(knowledge)，以支援臨床決策或創新醫療服務。隨著醫療服務與應用推陳出新(如，電子健康紀錄或行動醫療等)，與醫療機構因應政府政策需長期保存大量病患資料，讓醫療領域面臨如何有效的處理巨量資料。 然而傳統的關聯規則演算法，其效能上受到相當大的限制。因此，許多研究提出將關聯規則演算法，在分散式環境中，以Hadoop MapReduce框架實現平行化處理巨量資料運算。其相較於單節點 (single-node) 的運算速度確實有大幅提升。但實際上，MapReduce並不適用於需要密集迭帶運算的關聯規則演算法。 本研究藉由Spark記憶體內運算框架，在分散式叢集上實現平行化挖掘多維度多顆粒度挖掘關聯規則，實驗結果可以歸納出下列三點。第一點，當資料規模小時，由於平行化將資料流程分為Map與Reduce處理，因此在小規模資料處理上沒有太大的效益。第二點，當資料規模大時，平行化策略模式與單機版有明顯大幅度差異，整體運行時間相差100倍之多；然而當項目個數大於1萬個時，單機版因記憶體不足而無法運行，但平行化策略依舊可以運行。第三點，整體而言Spark雖然在小規模處理上略慢於單機版的速度，但其運行時間仍小於Hadoop的4倍。大規模處理速度上Spark依舊優於Hadoop版本。因此，在處理大規模資料時，就運算效能與擴充彈性而言，Spark都為最佳化解決方案。 / Under the population aging and population growth and rising demand for Healthcare. Healthcare is facing a big issue how to effectively deal with huge amounts of data. Cased by new healthcare services or applications (such as electronic health records or health care, etc), and also medical institutions in accordance with government policy for long-term preservation of a large number of patient data. But the traditional algorithms for mining association rules, subject to considerable restrictions on their effectiveness. Therefore, many studies suggest that the association rules algorithm in a distributed computing, such as Hadoop MapReduce framework implements parallel to process huge amounts of data operations. But in fact, MapReduce does not apply to require intensive iterative computation algorithm of association rules. Studied in this Spark in-memory computing framework, implemented on a distributed cluster parallel mining association rules mining multidimensional granularity, the experimental results can be summed up in the following three points. 1th, when data is small, due to the parallel data flow consists of Map and Reduce, so not much in the small-scale processing of benefits. 2nd, when the data size is large, parallel strategy models and stand-alone obviously significant differences overall running time is 100 times as much when the item number is greater than 10,000, however, stand-alone version cannot run due to insufficient memory, but parallel strategies can still run. 3rd, overall Spark though somewhat slower than the single version in small scale processing speed, but the running time is less than 4 times times the Hadoop. Massive processing speed Spark is still superior to the Hadoop version. Therefore, when working with large data, operational efficiency and expansion elasticity, Spark for optimum solutions.

中國自推動改革開放政策以來，經濟成長迅速，國民所得不斷提升，醫療需求與日俱增；再加上中國為順利加入WTO，2000年起更釋放醫療利多措施，放寬外資投入中國醫療服務市場限制。為此，旺旺集團旗下之湖南旺旺醫院搶得機先，於2005年底開業，不惟成為《中外合資、合作醫療機構管理暫行辦法》頒布後，中國第一家中外合資大型綜合醫院；亦是台商在大陸興建完成且正式營運之首家醫療機構，甚具指標性意義。 本研究除介紹中國醫療產業環境及相關政策法令外，更以個案研究法探討湖南旺旺醫院之興建動機、進入模式及經營策略。透過深入訪談並輔以次級資料分析，本研究發現，目前中外合資醫療機構由於數量少、進入時間短，尚不足以撼動公立醫院的地位，但在中國「看病難，看病貴」問題依然無法有效解決的情況下，以效率及品質著稱的民營大型醫院，應有相當之競爭優勢與發展空間。湖南旺旺醫院營運迄今已兩年餘，其透過醫院資訊系統建構整體醫療流程、以制度及人才奠定厚實根基等著重內部發展之經營策略，已逐漸獲得病人信賴並在經營實績上漸受肯定，應可供作其他跟進者發展布局參考。 至於兩岸醫療交流合作議題，由於台灣醫師薪資普遍較高，未必是符合成本的必然選項，建議應善用台灣管理經驗，就地建置系統性人才來源，方能掌握雙贏契機。總之，無論台資企業或醫療機構，唯有入境問俗、順勢而為，改變傳統思維與既有作法，才能在競爭激烈的中國醫療市場占有一席之地。 / Since China started to adopt the reforming and opening-up policy, it has seen rapid economic growth and ever-increasing medicare demand. To join WTO, China opened its medicare service industry for foreigners to invest in year 2000. Given such a background, the Want Want Group pioneered to found the Hunan Want Want Hospital—the first Chinese-foreigner joint ventured large general hospital following the dictum of “Interim Measures for Administration of Chinese-foreign Joint Venture and Cooperative Medical Institutions”. The hospital consequently sets an example of such joint ventures. In addition to discuss the environment of the Chinese medicare service industry and corresponding policies/regulations, this study explores the founding motivations, the entry mode, and the set of management strategies of Hunan Want Want Hospital. Through in-depth interviews and secondary data analysis, the study finds that owing to the still-small number and the still-short history of which, Chinese-foreigner joint hospitals have not yet gained the high ground to challenge public hospitals’ position in China. However, the study also finds that large private hospitals, renowned for their efficiency and quality, own substantial competitive advantage and expansion potentials. As an example for followers to emulate, Hunan Want Want Hospital has nurtured trust among its customers and performed well on several fronts because it developed a comprehensive information system to handle details of complicated medicare procedures, set up concrete rules for layers of management, and well-utilized human resources after more than two years’ operation. As far as the cross-straight medicare cooperation is concerned, this study finds that disparity in human resource cost across the straight may be an issue for Chinese-foreigner joint hospitals in China to address, and suggests that a win-win situation is achievable through the import of Taiwanese management expertise as well as the localization of human resource management. To conclude, Taiwanese medicare services, just like Taiwanese businesses in China, should adapt to Chinese local market environment and change accustomed management mindset so as to survive and grow in the Chinese medicare market.

在現代外科實務中，我們今天認為是標準作業程序的手術，追溯到初期可能是激進創新。多年來，外科技術雖然已經有頻繁的修改，但往往是漸進式地。心臟和血管外科領域中的大多數創新並沒有導致日常實踐劇變。然而，在過去的幾年中，在我服務的醫院和全世界，我看到了治療腹主動脈瘤 (AAA) 的典範轉移，亦即主動脈腔內修復 (EVAR)。 相對於傳統開腹手術修復 （OSR），主動脈腔內修復較傳統開腹手術修復有顯著較低的手術死亡率。不過，長遠來說，總死亡率或動脈瘤相關死亡率並無差異；而主動脈腔內修復有較高的植入物相關併發症和必須再次手術的機率，且成本更高。然而，主動脈腔內修復還是成為腹主動脈瘤治療的支柱。這是為什麼？ 除了是激進的技術創新，主動脈腔內修復也是技術頓悟。傳統上，醫療服務是典型的技術輔助服務情境，其中包含兩個單獨的、然而是密切相關的溝通系統： 一個是產業與醫師之間，另一個是醫師與病人之間。醫師居於樞紐地位，不僅確保治療之執行，而且還要評估結果。由於現代資訊與通信技術的發達，病人可以方便地搜尋輔助醫療文獻資訊、線上資訊和個人社會網絡的意見。這就像是詮釋者的作用。這詮釋者的解釋對病人、外科醫生、和醫療產業界產生了實質上重大的影響，反之亦然。以前在這服務體系中互相分離的部分現在可以緊密地互相配合了，這與服務導向邏輯中價值共同創造的概念是不謀而合的。 總之，對多重利益相關者之意義提升是臨床醫療服務典範轉移的原因。在醫療行業中引入服務導向邏輯的概念的重要性，不論是在日常實務和創新策略上的意義都是不容忽視的。醫療服務中，多重利益相關者比以前更涉及共同創造價值的過程。未來的創新者除了專注在技術和科技上，更必須考慮該創新對多重利益相關者之意義提升。 / In modern surgical practice, what we consider as standard procedures today may be radical innovations dated back to the early days. Over the years, there has been frequent modification of surgical techniques, often incremental though, and most innovations in the field of cardiac and vascular surgery didn’t result in drastic changes in the daily practice. However, during the past several years, I have been witnessing a paradigm shift in the treatment of abdominal aortic aneurysm (AAA) in my hospital and worldwide towards endovascular aortic repair (EVAR). In comparison to the traditional open surgical repair (OSR), EVAR was associated with a significantly lower operative mortality than OSR. However, no differences were seen in total mortality or aneurysm-related mortality in the long term, and EVAR was associated with increased rates of graft-related complications and reinterventions and was more costly. Nevertheless, EVAR is becoming the mainstay of AAA treatment. Why is this? Except for being a radical technology innovation, EVAR is also a technology epiphany. Traditionally, medical service is a typical technology-assisted service encounter, consisting of two separate, however, closely inter-related communication systems: one between the industry and the physician, and the other one between the physician and the patient. The physician is of the pivot role that not only ensures the execution of treatment but also evaluates the results.With modern information and communication technologies, patients caneasily search information from paramedical literatures, online information, and opinions from personal social network. This serves the emerging role of an interpretor. This interpretors’interpretation has substantial influence on patients, surgeons, industry, and payers and vice versa. Previously separated parts in the service system now can be closely inter-related. This is in concordance with the concept of co-creation of value in service-dominant logic. It is concluded that newly defined meanings to multiple stakeholders are the reasons for paradigm shift in clinical medical service. The importance of introduction of the concept of service-dominant logic into the medical industry, both in daily practice and in innovation strategy can never be over-emphasized. Multiple stakeholders are being involved much more than before in the process of co-creation of value in medical service.Future innovators must concentrate on meanings to multiple stakeholders as well on techniques and technologies.