由於醫療服務具高度專業性，故醫療照護市場長期存在資訊不對等的問題。隨著消費者利益保護及病人權利運動的興起、民眾被要求在自己的健康上承擔更多的責任，積極參與健康決策、新資訊科技的發明，使得醫院醫療與服務品質資訊的收集更容易且成本更低廉，因此，歐美各國近年來積極建立健康照護市場的品質資訊，發展醫院品質報告卡，提供民眾就醫選擇所需的資訊，期望能達成保障民眾的醫療權益，同時促使醫院提升醫療與服務品質，及增進醫療照護市場運作效率的目標。 台灣自1995年起實施全民健康保險制度，醫院與中央健康保險局的特約率達90%以上，民眾享有極大的自由選擇就醫地點及醫院，然而到目前為止，仍然欠缺足夠的醫院醫療與服務品質資訊提供給民眾做為選擇醫院的參考。其次，相關研究的結果顯示，台灣民眾對於就醫選擇資訊的提供有高度的興趣，且對民眾就醫選擇決策亦有重大的影響。 目標：本研究旨在由民眾觀點篩選醫院醫療與服務品質報告卡的指標項目，及採用創新擴散理論(innovation diffusion theory)，以結構方程模式(structural equation model)探討住院病人對醫院醫療與服務品質報告卡創新特性的知覺、態度及使用意願。 方法：本研究首先以推動社會福利、關心民眾健康權益及病人團體的30位專家為研究對象，進行二回合的德菲法(Delphi method )問卷調查篩選醫院醫療與服務品質報告卡的指標項目。其次以台北縣市不同層級及權屬別的八家醫院內、外科共500位住院病人為研究對象進行面訪問卷調查，探討住院病人創新接受度、對醫院醫療與服務品質報告卡創新特性的認知、態度及使用意願，並以結構方程模式進行研究假說與架構的驗證。 結果：1.由民眾觀點所選出屬於高適用性且高重視度的指標項目計有院內感染率、手術傷口感染率、住院病人對醫師病情解說內容的滿意度、門診病人對醫師服務態度的滿意度等九項；2.只有17.2%的住院病人在填問卷前有聽過醫院醫療與服務品質報告卡這個名詞；3.有80.2%的住院病人認為醫院醫療與服務品質報告卡對選擇醫院是非常有價值或有價值的；4.住院病人對服務品質指標的瞭解程度相對地高於對醫療品質指標的瞭解程度；5.對呈現方式的瞭解程度由高至而低排序，依序為星號、百分比、長條圖；6.影響「住院病人是否看懂醫院醫療與服務品質資訊」的因素，在控制其他變項的影響後發現，教育程度愈高者、年齡愈輕者、個人平均月收入較高者，較看懂醫院醫療與服務品質報告卡範例中指標資訊；7.創新特性中，「相容性」及「結果展示性」對「對醫院醫療與服務品質報告卡的態度」具有正向的顯著影響；8.「知覺有用性」、「對醫院醫療與服務品質報告卡的態度」及「創新接受度」對「使用醫院醫療與服務品質報告卡的意願」具有正向的顯著影響；9.影響住院病人「對醫院醫療與服務品質報告卡的態度」最主要因素為「相容性」，且達到統計上的顯著水準；10.影響住院病人「使用醫院醫療與服務品質報告卡的意願」的最主要因素為「對醫院醫療與服務品質報告卡的態度」，且達到統計上的顯著水準；11.最後要特別強調的是，本研究的新發現為「知覺有用性」、「知覺易用性」、「相容性」、「結果展示性」、「創新接受度」，兩兩之間具有統計上之顯著相關，這是本研究與以往相關研究結果的最大不同發現。 結論：住院病人認為醫院醫療與服務品質報告卡對選擇醫院是有價值的，因此，建議行政院衛生署可考慮主導，整合醫院評鑑、全民健康保險申報及病人滿意度調查的資料，分區分醫院等級，評比其在高適用性且高重視度的九項指標項目之表現，以星號及百分比的形式呈現，再以小手冊及網際網路查詢的方式對外公佈，並加強對民眾的宣導教育，讓民眾可以將品質資訊運用在就醫選擇決策上，使民眾成為明智的醫療服務消費者及醫療與服務品質的共同監督者，以提升醫療體系的運作效能。 / There exists information asymmetry between providers and consumers in healthcare market due to the highly specialized knowledge in this market. Consumers were asked to bear more responsibility on their own health and to participate in the formulation of healthcare strategies and the inventions of new technology as the uprising in the movement of consumer right protection. These would result in the reduction in costs related to the medical services and information collection. Therefore, western countries have aggressively established the medical information system and developed hospital report cards in order to protect consumers’ right, to improve quality of medical services, and to increase the efficiency of healthcare market by providing service information to consumers. Taiwan initiated the National Health Insurance since 1995 with the facility contract rate reaching over 90%. This provides consumers great access to healthcare institutions. However, few service data have been provided to consumers as a reference for the choice of providers to date. In addition, previous studies showed that consumers were interested in obtaining available service information and these information have a great influence on consumers’ decision of providers. Objectives: The purposes of this study were to select indicators of hospital report cards from public’s perspective and to adopt the innovation diffusion theory and structural equation modeling to explore inpatients’ perception characteristics of innovation, attitudes toward, and willingness to use hospital report card. Materials and Methods: Firstly, we selected 30 subjects who were experts in social welfare or consumer right to participate in two rounds of Delphi investigation to select appropriate indicators of hospital report card. Secondly, we purposely ask for the permission from eight hospitals representing different accreditation levels and ownerships to allow us to select 500 medical and surgical inpatients to conduct a face-to-face interview regarding their innovativeness, perception characteristics of innovation, attitudes toward, and willingness to use hospital report cards. Finally, we used structural equation modeling (SEM) to test research hypotheses by way of. Results: We found that (1) from publics’ perspective the most applicable and important indicators include nosocomial infection rate, postoperative infection rate, inpatient’s satisfaction toward physician’s explanation, and outpatient’s satisfaction toward physician’s service attitudes; (2) only 17.2% of surveyed sample heard the term “hospital report card” before; (3) a total of 80.2% of inpatients considered hospital report cards to be very valuable or valuable for the selection of providers; (4) inpatients understood more in service indicators than clinic indicators; (5) the order of inpatients’ preference in presentation of hospital report cards was to use stars, percentages, and bar charts; (6) those who had higher education and higher monthly incomes, and were younger were more likely to understand the information provided by hospital report cards after adjusting for other factors; (7) among inpatients’ characteristics of innovation toward hospital report card, ”compatibility” and “result demonstrability” had significant positive influence on ”inpatients’ attitude toward hospital report card”; (8)”perceived usefulness”, “inpatients’ attitude toward hospital report card”, and “inpatients’ innovativeness” had significant positive influence on ”inpatients’ willingness to use hospital report card”；(9)”compatibility” had significant positive influence on “inpatients’ attitude toward hospital report card”；(10)“inpatients’ attitude toward hospital report card” had significant positive influence on ”inpatients’ willingness to use hospital report card”；(11)finally it is worth emphasize that this study had a new finding that ”perceived usefulness”, “perceived ease to use ”, “compatibility”, “result demonstrability ”,and “inpatients’ innovativeness” had significant positive correlation between each other. Conclusions: We concluded that inpatients considered hospital report cards to be valuable for the selection of hospitals. Therefore, it is recommended that hospital report cards be initiated by the Department of Health by integrating the information from hospital accreditation, medical claims data from the National Health Insurance, and survey of patient satisfactions. The rankings of hospital shown on report cards can be presented in stars or percentages, and these pieces of information can be released through booklet or Internet. In addition, consumers should be educated to use hospital information in order to monitor hospital performance and improve the efficiency of healthcare delivery system. / 目 錄 誌謝……………………………………………………………… Ⅰ 摘要……………………………………………………………… Ⅲ Abstract………………………………………………………… Ⅴ 目錄……………………………………………………………… Ⅶ 表目錄……………………………………………………………… Ⅹ 圖目錄……………………………………………………………… Ⅻ 第一章 前言……………………………………………………… 1 第一節 研究背景與動機………………………………… 1 第二節 研究目的與研究問題…………………………… 5 第三節 研究的重要性與預期貢獻……………………… 6 第二章 文獻探討………………………………………………… 8 第一節 醫院品質報告卡的沿革……………………………… 8 第二節 醫院品質報告卡的指標項目………………………… 15 第三節 醫院品質報告卡的影響與推行障礙………………… 27 第四節 醫療品質指標系統及品質報告卡的發展步驟……… 32 第五節 創新擴散理論………………………………………… 37 第六節 結構方程模式………………………………………… 43 第七節 國內外相關實證研究之結果………………………… 48 第八節 綜合討論……………………………………………… 76 第三章 以德菲法篩選醫院醫療與服務品質報告卡之指標項目. 79 壹、研究方法……………………………………………………… 79 第一節 研究設計與流程………………………………………… 79 第二節 研究對象………………………………………………… 79 第三節 研究工具………………………………………………… 81 第四節 資料處理與分析………………………………………… 95 貳、研究結果……………………………………………………… 95 第一節 問卷回收情形…………………………………………… 95 第二節 描述性統計分析………………………………………… 96 第三節 第一回合與第二回合問卷調查結果差異分析…………105 參、討論……………………………………………………………106 第一節 重要研究結果討論………………………………………106 第二節 研究限制…………………………………………………108 第四章 住院病人對醫院醫療與服務品質報告卡的認知、態度 與使用意願……………………………………………… 110 壹、研究方法………………………………………………………110 第一節 研究架構、目的與假說…………………………………110 第二節 研究對象…………………………………………………118 第三節 研究變項之操作型定義…………………………………121 第四節 研究工具…………………………………………………124 第五節 資料處理與分析…………………………………………126 貳、研究結果………………………………………………………128 第一節 問卷信度及效度的檢定…………………………………129 第二節 樣本基本特質與研究變項的統計分析…………………130 第三節 研究假說與架構的驗證…………………………………170 參、討論……………………………………………………………178 第一節 重要研究結果討論………………………………………178 第二節 研究限制…………………………………………………187 第五章 結論與建議………………………………………………188 第一節 結論………………………………………………………188 第二節 建議………………………………………………………191 參考文獻……………………………………………………………194 附錄…………………………………………………………………209 附錄一、德菲法問卷專家效度名單………………………………209 附錄二、德菲法問卷專家名單……………………………………210 附錄三、醫院品質報告卡指標項目適用性及重要性評分問卷 212 附錄四、醫院品質報告卡指標項目適用性及重要性評分問卷 (第二回合) ………………………………………………224 附錄五、住院病人對「醫院醫療與服務品質報告卡」的認知、 態度與使用意願之研究問卷專家效度名單……………246 附錄六、住院病人對「醫院醫療與服務品質報告卡」的認知、 態度與使用意願之研究…………………………………247 附錄七、醫院醫療與服務品質報告卡的範例……………………254 表目錄 表2-1品質報告卡的種類及指標項目…………………………… 20 表2-2台灣有關醫療品質指標的實證研究……………………… 50 表2-3台灣用來評估醫院醫療品質的指標彙總表……………… 56 表2-4有關民眾(病人)選擇醫院(醫師)考量因素的實證研究… 58 表2-5台灣有關醫院品質報告卡及民眾就醫選擇資訊需求的相 關研究 ……………………………………………………… 66 表3-1本研究初步選取醫院醫療與服務品質指標的來源或依據…84 表3-2本研究所採用醫院醫療與服務品質指標的操作型定義……87 表3-3問卷發放及回收情形…………………………………………96 表3-4德菲法專家問卷分析結果……………………………………99 表3-5適用性前十名指標項目及其平均值 ………………………103 表3-6重視度前十名指標項目及其平均值 ………………………104 表3-7適用性與重視度交叉分析矩陣表 …………………………104 表3-8高適用性且高重視度指標項目 ……………………………105 表3-9Wilcoxon Signed Ranks Test 檢定結果………………… 109 表4-1研究對象分配表—依層級別、權屬別及性別分 …………120 表4-2預試問卷各成份信度結果 …………………………………125 表4-3有效樣本分佈情形—依醫院別 ……………………………131 表4-4樣本個人基本特質與就醫選擇資訊搜尋及需求狀況 ……133 表4-5對醫院醫療與服務品質報告卡的認知 ……………………137 表4-6對醫院醫療與服務品質報告卡之指標及呈現方式的瞭解 程度…… ……………………………………………………139 表4-7醫院醫療與服務品質報告卡創新特性之描述性分析 ……140 表4-8醫院醫療與服務品質報告卡的態度及使用意願之描述性 分析………………………………………………………… 144 表4-9創新接受度量表之描述性分析 ……………………………145 表4-10住院病人自覺醫院醫療與服務品質報告卡對選擇醫院有 無價值影響因素的雙變項分析……………………………147 表4-11病人自覺品質報告卡對選擇醫院有無價值影響因素之複 迴歸分析……………………………………………………149 表4-12住院前有無先探聽醫院醫療與服務品質資訊影響因素的 雙變項分析…………………………………………………151 表4-13住院前有無探聽醫院醫療與服務品質資訊影響因素之複 迴歸分析……………………………………………………153 表4-14住院病人是否看懂醫院醫療與服務品質資訊影響因素的 雙變項分析…………………………………………………155 表4-15住院病人是否看懂品質資訊影響因素之複迴歸分析……157 表4-16住院病人是否需要醫院醫療與服務品質報告卡影響因素 的雙變項分析………………………………………………159 表4-17住院病人是否需要醫院品質報告卡影響因素之複迴歸分 析……………………………………………………………161 表4-18住院病人會不會參考醫院醫療與服務品質報告卡影響因 素的雙變項分析 …………………………………………163 表4-19住院病人會不會參考醫院品質報告卡影響因素之複迴歸 分析…………………………………………………………165 表4-20住院病人是否會更換就醫醫院影響因素的雙變項分析…167 表4-21住院病人會不會更換到其他的醫院看病影響因素之複迴 歸分析…… ………………………………………………169 表4-22住院病人創新接受度、對醫院醫療與服務品質報告卡創 新特性之知覺、態度與使用意願理論架構因果模式之配 適度檢定結果………………………………………………171 表4-23整體模式之多元相關平方(SMC) …………………………171 表4-24外因潛在變項與其測量變項關係之標準化係數之檢定…173 表4-25內因潛在變項與其測量變項關係之標準化係數之檢定…174 表4-26潛在變項間之因果關係的標準化係數之檢定……………174 表4-27外因潛在變項間相關係數之檢定…………………………175 表4-28研究模式的間接、直接與整體效果………………………175 表4-29研究假說檢定結果…………………………………………176 圖目錄 圖2-1Rogers的創新--決策過程典範………………………………41 圖3-1德菲法研究流程………………………………………………80 圖4-1研究架構 ……………………………………………………111 圖4-2本研究之結構方程模式關係路徑圖 ………………………177

本論文緣起於本研究者積三十年於醫學教育之教學、研究、服務及醫院臨床經驗之心得，透過近年於國立政治大學商學院EMBA策略管理課程之學習，乃試以北醫大為個案實例，探討大學教學醫院與醫學院資源互惠之最適經營策略，並嘗試提出可能之最適經營模式。 基於管理哲學之建立，首在掌握探討經營目標之界定，運用可能之資源，判別環境之變化，而採取最適經營策略，進而提出最適經營模式。而本研究者，以商學院之理論基礎，檢測台北醫學大學附屬教學醫院之教育目標及使命，深受近年台灣醫學、醫藥之嚴峻挑戰與變遷，以及政府健保政策等之鉅變下，所擁有之有限醫學教育教學資源，必須與現有醫學院系之資源，有所調整與互惠運用之經營策略，故本研究者以近距離觀察，與獨有之醫學教學及臨床實務任務，作此研究，貢獻予台灣各大學教學醫院與醫學院資源互惠之經營策略參考。 關鍵詞：大學教學醫院、醫學院、醫學教育目標及使命、資源互惠、最適經營模式、調整與互惠運用、經營策略 / A study to develop effective cooperation and beneficial collaboration in resources between teaching hospitals and medical schools- a case study of Taipei Medical University Hospital This paper seeks to explore ways through which medical schools and teaching hospitals can better share their medical educational resources. With his thirty odd years of teaching and clinical experience in both Taipei Medical University and the university hospital, coupled with his EMBA structural and management learning, the author plans to develop an effective model drawing on both business management theories and his personal familiarity with the hospital management climate. With a current scarcity in medical education resources, caused by reasons ranging from the government’s recent instatement of the medical care program to the newest wave of changes in medical ethics in Taiwan, the author proposes that Taipei Medical University and its teaching hospital must re-distribute and re-organize the current model with which teaching resources is deployed if it wishes to uphold its vision of educating well-rounded young doctor. To successfully re-invent an effective model, the author proposes to employ a business management approach. According to the basic philosophy of management, a successful model must be established with a firm objective for the institution, an honest evaluation of the institution’s available resources, and careful observation of the current climate of the market. These principles would be the building blocks in the current paper for the development of an efficient model for medical education resource allocation. The following research spans a period of six years, from 2001 to 2007. Done with strict scientific methods, the research aims to provide solutions for medical school and teaching hospitals in Taiwan a better way to allocate medical education resources, and ultimately contribute to the future advancement of medical education and management in Taiwan. Key word：medical school 、teaching hospitals、medical educational resources、effective cooperation and beneficial collaboration in resources、medical education and management、efficient model

University of Macau / Faculty of Social Sciences and Humanities / Department of Government and Public Administration

本計劃因應台灣地區大量適婚年齡男女未嫁娶與少子化，所以許多人將寵物視為家庭的一份子，讓台灣寵物市場穩定成長，因此計劃打造一個以寵物為主題的行動平台，本平台將建立一個結合交友、社群與電子商務的綜合產業生態圈。 本計劃規劃的執行方式為藉由App的方式，讓會員免費使用交友與社團服務，建立以寵物為共同興趣的大型社群；再透過大數據與LBS機制（Location-Based Service基於位置的服務）進行寵物用品與食品相關的電子商務與廣告媒合。 本計劃預期效益為三年內產生8千萬元台幣營收與締造會員30萬人；針對個人方面，本計劃為對寵物有興趣的男女進行交友媒合，並為其建立實體與線上的交流社團；針對廠商方面，本計劃為大型寵物食品用品廠商建立行銷廣告通路，為小型寵物食品用品與文創商品廠商建立銷售通路。在商家方面，本計劃為寵物用品店、寵物醫院、寵物旅館、寵物美容院、寵物餐廳等等建立與客戶連絡與溝通管道。

本論文對於醫療市場的生產績效研究，係由兩篇獨立的學術研究報告所組成，研究重點在於利用非參數資料包絡分析方法 ( nonparametric DEA approach )，估計醫院的生產技術，以衡量醫院的技術效率及不同年度間之生產力變動，進而分析不同醫院間，生產績效差異的主要原因。本論文所採用的研究方法與探討的主題，不同於國內既有的相關文獻。 第一部分：生產不確定性與醫院效率 本部分主要探討在醫院面對不確定性時的效率評估。一般而言，醫院有兩種生產上的不確定性來源：醫師或醫院的診療結果所導致的生產不確定性；及消費者對醫療服務需求的不確定性 (Arrow, 1963)。當醫院面對生產不確定性時，醫院效率將與廠商如何處理不確定性問題有關，亦即，當廠商事前規劃愈縝密，未來可能的產出失靈水準愈低，則其生產效率表現愈佳。本文利用民國 82 及 83 年（準）醫學中心與（準）區域醫院資料，模擬醫院在面對生產不確定性時，各種可能的產出失靈水準，以chance constrained DEA 模式 (Land, Lovell and Thore, 1993) 估算醫院的隨機技術效率，並與傳統、確定性的DEA模式所得到之結果，做一比較。 Chance constrained DEA模式與傳統DEA模式的不同，在於前者估計出的生產前緣，並不總是包絡所有的樣本點，亦即，允許某廠商之產出超越生產前緣或說允許產出失靈可能性之存在，而後者則否。實證結果發現，在chance constrained DEA模式下，私立醫院的技術效率高於公立醫院，且呈現統計顯著性的差異，但兩者間的差異隨著醫院事前準備程度的提高而縮小；而傳統DEA模式也顯示，私立醫院的技術效率確實顯著地高於公立醫院。此外，若產出失靈水準夠低，則chance constrained DEA模式的效率值與傳統DEA模式的效率值，兩者間的分配會呈現統計顯著性差異。 在面對生產不確定性時，欲提升公立醫院的生產效率，應提高廠商事先規劃的程度，才能與私立醫院之生產效率並駕齊驅。一般而言，廠商事先準備的程度高低，與醫院本身的特性有關，因此，欲改善公立醫院緩衝產能的準備程度，以降低產出失靈水準，有必要進行體制層面的改革，亦即，從進行人事變革、財務之授權與彈性化等方向開始做起，如此應可提高公立醫院的生產效率。 第二部分：全民健康保險制度與醫院生產力變動 全民健保實施後，民眾對醫療服務的可近性提高，醫院間的市場結構改變，因此，醫院生產力與效率的提升，成為眾所關切的焦點。為瞭解醫院在全民健保實施後，資源是否有效配置，本部分利用民國 82 至 86 年醫學中心、區域醫院與地區醫院等大小型醫院資料，以範疇DEA模式估計Malmquist生產力變動指標，並將之分解為技術變動、純技術效率變動、及規模效率變動等三項變動來源。 實證結果發現，從82至86年醫院整體平均效率而言，CRS（VRS）生產技術下的平均效率為 66.00%（74.87%），表示不論大小型醫院，平均而言，皆存在技術不效率的情形。再者，在民國84年，亦即全民健保實施的年度，其效率水準明顯較其他年度為低，其餘年度的效率水準都相對較高，此一結果意謂，政策干擾對於醫院效率表現的影響，是短期性的。另外，小型醫院皆較大型醫院不效率，兩者的效率差異呈現統計顯著性；以權屬別而言，不論是大型醫院或小型醫院中的私立醫院，其生產效率均優於公立醫院，且兩者的效率差異呈現統計顯著性。而透過迴歸分析顯示，全民健保實施、權屬別之虛擬變數、佔床率、平均住院日、及以醫院產出衡量的集中度指標等，是影響醫院生產效率的重要因素。 從Malmquist生產力變動（　et al., 1994）來看，平均而言，82-86年間醫院生產力成長率約在 -3.06 % 左右。就生產力變動來源而言，技術成長率（-2.74 %）與整體效率成長率（-0.33 %）均為負，而技術變動則是阻礙生產力成長的主要原因。此外，若以醫院整體效率變動來源來看，平均而言，整體效率退步是由於規模效率變動所致（-0.74%）。 此外，本文著重在　et al.(1994)、Ray and Desli (1997) 及Grifell and Lovell (1998) 三種定義下的Malmquist生產力變動指標之比較。研究結果發現，Grifell and Lovell (1998) 的一般化Malmquist生產力指數，並沒有正確衡量廠商的生產力變動及其變動來源項。而利用Kruskal-Wallis檢定結果發現，三個模式中的生產力變動差異，並不具統計顯著性，而變動來源項（技術變動與規模效率變動）亦顯示相同的結果。 / This dissertation is focused on the efficiency and productivity studies of hospitals in Taiwan. It includes two independent academic papers. The primary intention is to introduce the newly developed ideas in the measurement of efficiency and productivity, rather than to create new ones. The utilization of these ideas has not, however, been discussion in print. And some of the arguments we used and brought together are new regarding to the literature of hospital efficiency and productivity measurement. Utilizing the non-parametric data envelopment analysis (DEA) approaches, efficiency scores and productivity change indexes were estimated. Efforts were made to explain the difference of productivity performance among individual hospitals. Nevertheless, the methods we used and the economic approach behind them distinguish this study from other empirical studies of the medical market. Part I　 Market Uncertainty and Hospital Efficiency This part of the dissertation is focused on the measurement of efficiency of hospitals, incorporating uncertainty. There are stochastic variations in production relationships for hospitals. Generally speaking, the uncertainty of hospitals comes from two major sources: the natural uncertainty of medical cares; and the uncertainty of demands for medical cares (Arrow, 1963). Given the uncertainty in the medical market, the efficiency of hospitals hinges on how decision-makers deal with it. Undoubtedly, an optimal planning of the output buffers improves the efficiency performance. Using the hospital survey data in 1993 and 1994, and employing the chance constrained DEA model (Land, Lovell and Thore, 1993), the stochastic efficiency indexes of public and private medical centers and regional hospitals were estimated. Compared with deterministic frontier enveloping a given set of sample observations all the time, the chance-constrained frontier envelops them most of the time. That is, the chance constrained DEA allows the possibilities of output failure. Imposing different values of output failure probability, the estimation results were compared with the traditional (deterministic) DEA models. The empirical evidences of the chance constrained DEA model showed that, on average, private hospitals performed significantly better than public hospitals. This result matches with the result of the traditional DEA model. With Mann-Whitney U test, we compared the distributions of efficiency indexes under chance constrained DEA and deterministic DEA models. The test results showed that the difference between these two different models is statistically significant given a higher probability of output failure. These results imply that the nature of risk and the manipulation for risk are different for public and private hospitals. We also find that that the efficiency performance of public hospitals could be improved by the increasing of its reserve capacity. Part II　 National Health Insurance and Hospital Productivity Change In this part of the dissertation, we examine the impact of NHI on hospitals, and trace the sources of hospital productivity growth in Taiwan. To pursue our goal, we employ a data consisting of 157 medical centers, regional hospitals and district hospitals over the period 1993 to 1997, and resort to the Malmquist productivity index to measure total factor productivity change. The index could be decomposed into three components: technical change, pure technical efficiency change and scale efficiency change. The estimation technique used in the study is the deterministic non-parametric DEA approach. The results we find are revealing and suggestive to the public and the government in order to promote and assure the efficient delivery of quality health care. The average efficiency scores are 66.00% (74.87%) for CRS (VRS) technology and it means that there are substantial efficiency losses for the sample hospitals during the study period. The efficiency score of the hospitals as a whole in 1995 (the beginning year of NHI) was much lower than the other 4 years' efficiency scores. A censored Tobit regression analysis is used and identifies that NHI policy, ownership, rate of bed occupancy, average length of stay and the output-specific concentration level were all the significant determinants of technical efficiency. Empirical results indicate that most medical care regions became more output-specific concentrated. Total factor productivity on average deteriorated at an annual rate of -3.1%, and it was dominated by substantial technical regresses at an annual rate of -2.74%. The small hospitals were severely affected by NHI. Furthermore, within large and small hospital groups, the difference in technical change was statistically significant, but the differences in TFP and the associated components between ownership were not. Special attention was paid to compare　 et al.(1994), Ray and Desli (1997) and Grifell and Lovell (1998) approaches to decomposing the Malmquist productivity index. Empirical results indicate that the first 2 approaches yield accurate productivity changes, while GL doesn't. However, they produce almost the same magnitude of average TFP. In addition, no significant differences in the measured technical change and efficiency change were found among the three approaches.