Objective¡G The purpose of this research is to explore the influences of the global budget implementation on the older stroke patient's outcome and medical quality. In further analysis, this study compared the differences of the older stroke patient's rehospitalization and complication across age groups, genders, regions, and the hospital¡¦s characters. Analysis of the real extent of the Global budget policy on the readmission of patients was focused on stroke-related outcomes and costs. This study also reviewed the Global budget policy on whether it has effective control of medical resources, and measured its impact on medical care of patients, thus to control costs and improve quality of care. Method¡G The data were derived from the National Health Insurance database and the Taiwan census data. The study periods were 1999-2000 and 2004-2005. In this research, descriptive analysis was used to examine the older stroke patient's outcome and medical quality. T -test and chi-square was used to investigate the outcome and medical quality differences between medical institutions and personal characteristics. Logistic regression and linear regression model were used to detect and describes data trends. Results: Regarding Taiwan's overall four years of the older stroke patient's rehospitalization and complication, the status of infection and medical expenses showed significant growth trend after the Global budget policy implementation. For the medical institutions characteristics, the infection status of the non-for-profit hospital, medical center hospital, district hospital, teaching and non-teaching hospital were showing significant growth. For the personal characteristics, the infection status of male, female, aged 70-74, south and east regional were with significant growth. Conclusion¡G According to the study results, we found that the Global budget policy implemented in Taiwan was still need to be improved. We suggest the policy makers and the hospitals may use the ¡uGlobal budget policy implemented¡vas an indicator to monitor the quality of care and the outpatient care quality in Taiwan¡¦s healthcare system. Thus not only can reduce the unnecessary expenditure, but also can offer the general public better quality of healthcare and improve their quality of life.

Purpose: The Bureau of National Health Insurance (BNHI) use the Global Budget (GB) System to control the medical expense growing up, and it was put into practice in each hospital in July 2002. This research explores the medical expense before and after the GB System was put into practice. Method: Using the data of BNHI, we explore the average daily cost of admission data of schizophrenia (ICD-9 CM code 295) in acute ward. The total cost were separated into several detail subjects (drug amount, psychiatric treatment amount, test amount, self payment amount, and other) to be analyzed. Data of 1999 and 2000 were selected as ¡§before GB period¡¨, and 2003 and 2004 were selected as ¡§post GB period¡¨. We also collect following variables to adjust the effect of GB. Patient¡¦s data: age, gender, comorbidity, insurance count, urbanization. Hospital data: hospital levels, hospital power, geographic location, owner, teaching hospital. Doctor data: age, gender. The 14-day and 30-day re-admission rate. Results: The growth of total medical expense is 40% after the implement of GB, which is lower than the estimated 60%. In the psychiatry, the total cost or subgroups of the total cost were increased. The average daily drug amount were 150.42 NTD before the GB¡Aand192.53 NTD post GB; the psychiatric treatment average daily amount was 551.24 NTD before the GB, and 737.94 NTD post GB; the average daily test amount was 75.54 NTD before the GB, and 90.60 NTD post GB; the average other amount was 970.03 NTD before the GB, and 1317.06 NTD post GB; the average daily total medicine amount was 1773.18 NTD before the GB, and 2371.92 NTD post GB. After adjusting the patient, doctor, hospital, and studying year, the before/after GB is still an independent factor to predict higher cost in every amount. Nevertheless, the growth of the average daily total medicine amount is minimized to 14.83% which is much lower than the growth of 40% of the total medical expense after the adjustment of the individual items. After adjusting patient¡¦s, hospital¡¦s and doctor¡¦s factors, the 14-day and 30-day re-admission rates are lower than ¡§before GB period¡¨. Conclusion: The short-term re-admission rate, one of the medical quality indicators, declined after the implement of GB and the growth of total cost at least was suppressed to the set goal. Various adjustments of medical behaviors are believed to be made to get the best cost-benefit.

According to the empirical study, it is confirmed that physician satisfaction has great influence on patient satisfaction, and the physician¡Vpatient relationship could also affect health quality. The agreeableness and satisfaction of the healthcare providers (especially the physicians) to reimbursement system therefore should be emphasized especially with the intervention of health insurance. The objective of the study is to investigate the agreeableness and satisfaction of dentists to global budgets and their contributing factors. We survey dentists practiced within the Southern Branch and the Kao-Ping Branch regions of the National health insurance bureau with questionnaire. The primary result is as following: 1. The satisfaction of dentists to global budget after implementation: Male dentists are more satisfied than female detests. Dentists over 40 years old or with more than 15 years of practice experience are more satisfied. Solo practitioners are more satisfied than those who are employed or in partnership. Dentists practiced at Kaohsiung city have better stultification within the Kao-Ping Branch region; while the dentists, work in Jia-yi county are more satisfied than those at Tainan city within the Southern Branch region. Dentists with greater patient volume per day or longer business hours per week are less satisfied. Lastly, dentists whose service points claimed per month didn¡¦t decrease after the implementation of global budget are more satisfied with the system. 2. The agreeableness of dentists to global budget after implementation: Male, older dentists agree more with the reimbursement system. Dentists with more or equal service points claimed per month after implementation agree more with the global budget system. But those increase service hours per week are less agreeable to the system. Within the Kao-Ping Branch region, the dentists practice in Pun-hu county, are more agreeable than those at Kaohsiung city; those work in Jia-yi are more in agreement than those at Tainan within the Southern Branch region. Opened questionnaire indicated that surveyed dentists showed negative feedback on t the appropriateness, equity, and standardization of peer review. They further suggested the operation of dental association should be transparent, and the names of the dental clinics should be made known to the public if there¡¦s fraud. Besides, they also made some constructive suggestions such as the establishment of the public record of the oral cavity examination, periodic oral examination, and improvement of professional medical technology. Theses suggestions should be useful to the dental association for professional and quality improvement, standard protocol development and to the Bureau of the National Health Insurance for policy evaluation.

ABSTRACT A Study of Key Decision-making Factors of Coping Global Budget System and Reformed Hospital Accreditation of a Regional Military Hospital Since the implementation of Global budget system in 2002, the constant controversy is continuous. In addition, the fulfillment of Reformed hospital accreditation is related to the amount of insurance payment. Under this double pressure, the medical institutions generally face the dilemma of operating difficulties. Besides these pressures, the Military hospital also has problems of budget and staff reducing. How to draft and execute the business strategy to achieve sustained development is a serious and important issue. In this study, a regional military hospital was chose as a research case. We point at analysis of medical industry environment , literatures review and ways of monitoring of Global budget system and Reformed hospital accreditation of research hospital. According to the characteristics of Global budget system and Reformed hospital accreditation, we adopted the Saaty¡¦s Analytic Hierarchy Process (AHP) to establish individual multi-estimate criteria models of the key decision-making factors of Global budget system and Reformed hospital accreditation of the hospital. And then by AHP qualitative and quantitative questionnaires, undertook research and analysis of various key decision-making factors. Finally, the Analytic Hierarchy Process was applied to calculate the weighting and to sequence the priority of these factors. To find out which hospital management operation system should be strengthen. The results of study showed that in light of coping Global budget system, the ¡§strategic management¡¨ is the most important key decision-making factors, which ¡§Cost control and financial management¡¨ and ¡§ Just distribution of reward¡¨ are the top priority. In addition, ¡§ Raise the medical quality of service¡¨ and ¡§quality of medical manpower¡¨ to fight for extra Global budget and own expense items are the important strategy of broadening resources. In the light of coping the Reformed hospital accreditation, the ¡§Decision making capacity¡¨ is the most important factors, particularly the ¡§leader¡¦s leadership of the decision-making¡¨. ¡§Reformed hospital accreditation progress-control table¡¨ and the ¡§Information system of management of Reformed hospital accreditation¡¨ can standardize the preparatory work as well as the control over the progress of preparations. ¡Ô

The Balanced Scorecard (BSC) was first proposed by Robert S. Kaplan, Professor of Accounting at the Harvard Business School, and David Norton, founder and president of a consulting firm in 1992. They elaborated the idea of strategic measurement system to oversee the performance of a business unit. The system is suitable for both profit and non-profit organizations. After ten years, BSC is proved to be a very powerful tool to inspect the performance of a company, also the implementation of a firm¡¦s strategy. National Health Insurance (NHI) in Taiwan was practiced in 1995. Medical service system had dramatic changes since that time. In order to keep financial balance, NHI develops new policies from time to time, reforms the reimbursement criteria, from fee-for-service to global budget. Hospitals face incessant new challenges. Military hospitals, belonging to non-profit government organizations, play an important role in medical services. It is absolutely important ¡§how to survive under such critical environment, and achieve the goal of permanent operation.¡¨ This thesis is a case study, taking an armed forces hospital as an example to construct its system of strategy management. By implementing the Balanced Scorecard, the hospital can reposition its role according to the mission. Then, the hospital can set up its vision and strategic objectives to draw the strategy maps. Within the four perspectives of the BSC, the hospital can select several measurements to evaluate their performance, then, they can know what has been changed and what needs to be improved. The Balanced Scorecard is the best management tool to implement a company¡¦s strategy. At present, BSC is applied to help strategy management in some hospitals. If it is applicable for a military hospital, it would be a great opportunity to overcome the competitive environment and to achieve the goal to run our military hospital permanently.

Abstract Hospital global budget payment of national health insurance in Taiwan starts from July 1, 2002. The payment of emergency department has fixed point-value from July 1 , 2002 to December 31,2003 ( one point of hospital global budget payment equals one NT dollar) . But the payment of emergency department becomes floating point-value, shared with out patient department from January 1,2004. Hospital global budget payment of national health insurance in Taiwan suppressed excessive medical supply through the mechanism of floating point-value. The emergency department of hospital in Taiwan can¡¦t refused patient¡¦s visiting by the regulation of law. We collect the figure of people¡¦s medical utility in emergency department of one regional hospital with 653 beds in Kaohsiung city from July 1 , 2002 to December 31,2003.( one point of hospital global budget payment equals one NT dollar)then the same data also collected from January 1,2004.to July 31,2005.( floating point-value),analyzed by T test. The research result indicates that : the numbers of patient¡¦s transfer to emergency department increased (p value: ¡Õ¡Õ0.05), the numbers of triage1,2 at emergency department increased (p value : ¡Õ¡Õ0.05), the numbers of emergency visiting each month increased (p value:0.036), the growth of admission don¡¦t have statistic significance (p value:0.509). Key word: global budget payment¡Bfloating point-value¡Btransfer¡Btriage

Since the global budget system carried out by National Health Insurance Bureau in 2003, hospital autonomy management practiced in 2003 as well as reviews carried by specialized doctors system established, local hospitals have faced critical impacts. The fluctuating point reimbursement was applied, it not only restrains the reimbursement received by the hospitals, but also causes management difficulties for local hospital as the fluctuating points shrink year by year. The number of western medical hospitals is decreasing. The number in 2000 was 575, but now only 500 local hospitals operate in Taiwan. For survival, local hospitals have to establish sound financial system in order to deal with changing national health insurance policies. On the other hand, they are encouraged to use strategy management theories to promote the competitiveness for local hospitals to well control their expenditures and create their income. The study has analyzed the statistical data from Statistical Office, Department of Health and National Health Insurance Bureau and integrated related literatures to understand the management strategies and responses of local hospitals under national health insurance policies and the economic, demographic and political environment. Results of the study will be provided for reference. Beside statistic data and literatures, strategy management concepts and theories were also adopted to clarify current policies of health insurance, reimbursement system and the situation of local hospitals to probe into the difficulties and possible solutions. Local hospitals were chosen to be the study subjects, and through SWOT Analysis, Poter¡¦s Five Force Analysis, Blue Sea Strategy and the findings from literature review, we found that (1)the financial gap of health insurance has transferred to medical organizations, especially local hospitals; (2)under global budget system, local hospitals have to increase income and decrease expenditures by transformation, running pay business or joint outpatient service; ¡]3¡^cost management is critical for local hospitals to establish internal strength; (4) referring to blue sea strategy to develop distinguished business and differential products can create niche for local hospitals to break through the bottleneck.

On coping with the¡§hospital-based self-management＂ project implemented by the National Health Insurance in Taiwan-----A case study of an Armed Forces Hospital The global budget payment system has been implemented in Taiwan＇s National Health Insurance (NHI) for dental care, Chinese medicine and basic western medicine since 1998, and for Western medicine hospital since 2002. The purpose of this payment system is to control the toal medical expenditure by a fixed annual budget. However, it used in Westewrn medical hospital is so complicated that the fulfillment of this new system will create a new competetion era for the hospitals if without associated set of measures, its complexity is far beyond our detection. The Bureau of NHI therefore carry out variable kinds of mamagement protocols such as ¡§global budgeting system by different area＂,¡§hospital-based self-management＂, and ¡§hospital in pursuit of excellence＂, so that each branch of NHI Bureau will own a fixed amount of budget and negotiate the separate amount with the hospitals. The military hospitals are facing a critical environment; the public budget and personnels of the hospital sponsored by the National Defense Department is decreasing; and the NHI has implemented the global budgeting system which will condense the growth rate of each hospital. The thesis is focusing on the study hospital＇s model of strategic management, establishing a criteria-monitoring system in the hospital in order to analyze the details of the operating performance , when negotiating the growth rate with the Burear of NHI, which is the most important part of the plan for hospital in persuit of excellence, will find out the abnormalities and the solutions for that iii problem. The result of this study showing the management information system in a hospital will provide immediate data, analyze it and help the superintendent make decisions. It is quite critical in such a competitive environment, the information system was proved to be effective and the hospital can achieve the vision of sustainable operationOn coping with the¡§hospital-based self-management＂ project implemented by the National Health Insurance in Taiwan-----A case study of an Armed Forces Hospital The global budget payment system has been implemented in Taiwan＇s National Health Insurance (NHI) for dental care, Chinese medicine and basic western medicine since 1998, and for Western medicine hospital since 2002. The purpose of this payment system is to control the toal medical expenditure by a fixed annual budget. However, it used in Westewrn medical hospital is so complicated that the fulfillment of this new system will create a new competetion era for the hospitals if without associated set of measures, its complexity is far beyond our detection. The Bureau of NHI therefore carry out variable kinds of mamagement protocols such as ¡§global budgeting system by different area＂,¡§hospital-based self-management＂, and ¡§hospital in pursuit of excellence＂, so that each branch of NHI Bureau will own a fixed amount of budget and negotiate the separate amount with the hospitals. The military hospitals are facing a critical environment; the public budget and personnels of the hospital sponsored by the National Defense Department is decreasing; and the NHI has implemented the global budgeting system which will condense the growth rate of each hospital. The thesis is focusing on the study hospital＇s model of strategic management, establishing a criteria-monitoring system in the hospital in order to analyze the details of the operating performance , when negotiating the growth rate with the Burear of NHI, which is the most important part of the plan for hospital in persuit of excellence, will find out the abnormalities and the solutions for that iii problem. The result of this study showing the management information system in a hospital will provide immediate data, analyze it and help the superintendent make decisions. It is quite critical in such a competitive environment, the information system was proved to be effective and the hospital can achieve the vision of sustainable operation

In recent years, the re-distribution of medical resources conducted by the government in general renders physicians to be anxious about the stability and fairness of their income. The worries are even aggravated by the policies such as ¡§secret in payment¡¨ or ¡§personalized payment¡¨ that are currently preceded by the hospitals. Since the as mentioned worries may affect physicians¡¦ attitudes toward their patients, factors affecting physicians¡¦ satisfaction in their income based on the stand point of ¡§salary justice¡¨ are thus important and will be the focus of the present research. Meanwhile, the influences of ¡§total budget system¡¨ on ¡§salary justice¡¨ and ¡§salary satisfaction¡¨ are also studied. The overall consequences to the physicians ¡§work attitude¡¨ are finally evaluated and analyzed in the present study. The research was conducted by distributing 319 questionnaires to the physicians belonging to eight hospitals in the middle area of Taiwan. Among these distributed questionnaires, 108 of them were retrieved. The retrieval rate is thus calculated as 33.9%. The results are presented as follows: 1.Gender, salary and position do not possess any influence on ¡§salary satisfaction¡¨ and ¡§working attitude¡¨. 2.A negative correlation is observed between ¡§age¡¨ and ¡§salary justice¡¨. This implies the elders demand higher base in their salary. 3.The more open in salary information and communications, the better in ¡§salary satisfaction¡¨. 4.The ¡§structure of income¡¨ should be consistent with one¡¦s recognition on the source of his or her salary. Together with a fair distribution in overall benefits would help in motivating positive work attitude. 5.More understanding in the method of benefit distribution as proposed in the ¡§total budget system¡¨ could lead to more negative attitude in working. 6.The ¡§total budget system¡¨ is still in the embryonic stage. No effects on ¡§salary justice¡¨ and ¡§salary satisfaction¡¨ have been observed yet. 7.A physician would possess a stronger commitment in job fair and team involvement when he/she feels satisfactory with the payment.

本研究的焦點主要圍繞在兩大主軸：社會鑲嵌性與決策，探討在行動者間社會網絡的關係結構下，決策的影響力與決策行為的社會性。換言之，本研究認為決策並非僅是理性的產物，更多的時候，反而是理性與非理性因素交互作用的結果。也就是說，決策必然鑲嵌在決策者間的社會網絡關係結構，任何的決策都無可避免的必須考量到決策者間的關係型態所造成的限制。本研究使用牙醫與中醫總額支付委員會作為研究的個案，除了讓社會網絡與決策網絡的邊界更清楚，更符合研究校度之外，也希望能夠進一步透過兩個案的分析，一方面透過社會網絡分析瞭解兩支付委員會可能的權力分佈與結構，二方面分析影響決策權力分佈與決策產出的關係機制為何，並藉此來驗證決策的社會鑲嵌性此一概念。 本研究使用事務討論、信任支持、法規諮詢與資源交換四個社會關係網絡來測量行動者在決策過程中的社會關係，並用以驗證決策者的決策影響力與決策的一致性是否鑲嵌在這四個網絡的結構當中。本研究透過社會網絡的問卷蒐集了牙醫支委會18筆與中醫支委會21筆資料（N=56），並透量化社會網絡分析方法中的集中性指數、派系、網絡密度、區截模型與縮影矩陣、MDS分析與QAP的相關與迴歸分析等分析工具，從個體、小團體層次、與總體的結構層次，分析牙醫與中醫支委會的行動者在網絡中的關係型態與位置角色。此外，更透過上述分析中所獲得的集中性指數的分析結果當作自變項，並放入迴歸模型之中，藉以驗證是否對集體決策產出的觀感造成影響。 總的來說，本研究可歸納以下研究結論：一、在牙醫與中醫支付委員會的個案中，委員決策的影響力與決策行為，確實都受到四個社會網絡結構的影響，驗證了決策的社會鑲嵌性此一觀點；二、無論從個體、小團體或總體結構的分析層次，得到的分析結果都很類似，具有決策影響力並與其他行動者有密切的社會關係的行動者，在牙醫支委會有牙醫全聯會的H11, H16與健保局的A2，但中醫支委會的部分，就沒有健保局的代表，反而僅有中醫全聯會代表，顯見在牙醫部門當中，權力的分佈屬於公、私部門間二元的機制，但中醫的部分僅有集中在中區中醫師；三、委員的出席確實會受到委員個人政策影響力與資源交換網絡的顯著影響，顯示個人政策影響力愈大，與其他委員資源交換關係愈頻繁的委員，參與會議的意願較高；四、從影響集體決策產出觀感的因素來說，事務討論關係與在事務討論網絡的派系重疊程度對集體決策產出的觀感有顯著且正面的影響，個人的決策影響力與年資反而有負面且顯著的影響。 本研究大的貢獻，一驗證了決策的社會鑲嵌性此一觀點，決策必須將社會關係變項考量，二是在公共行政領域中第一本以系統化的方式使用社會網絡分析工具的論文，非但具有示範性的作用，也跨越了過去公共行政網絡研究過於喻象的分析缺陷。根據分析結果，本研究提出以下四點政策建議：一、中醫支委會的健保局代表應當夠積極的與中醫全聯會的代表建立溝通的關係，以構築決策影響力的社會基礎；二、委員會中若不具決策影響力，又在社會關係上沒有跟其他行動者互動，則應考慮其存在的實質意義；三、由於年資長短對決策觀感會有負面影響，健保局應更積極的與年資較久的委員溝通請益，瞭解他們為何會對委員會的運作績效有負面的想法，藉以強化委員會的功能；四、加強委員之間的總額事務討論的交換意見的關係，有助於集體決策的產出。 / Decision making is a collective activity rather than an individual option. In literature, collective action can be symbolized as a network. The concept of network has emerged as an intellectual centrepiece in the field of public administration and the speedy development of social network analysis has facilitated “network research” to go beyond only a metaphor. However, most previous decision theories based on the concept of rationality have not seriously considered a network’s impact on the policy process. This research attempts to verify the causal relationship between social embeddedness and decision-making by examining how policy elites’ personal interactions shape individuals’ decision-making behaviour, influential power and the collective decision performance. This research focuses on the result of the mutual influence between rational and non-rational factors. Two cases (the Dental and Chinese Medicine Global Budget Payment Committees) are discussed by applying quantitative social network analysis in order to systemically expand the current understanding of the power distribution and its influential factors in these two decision making committees in Taiwan’s National Health Insurance domain. In regard to methodology, four participants’ social networks were designed not only to examine the social relationship between these committee members but also to analyse the phenomenon of social embeddedness in these two cases. There are totally 39 successful respondents (apx. 80% response rate, N=56) and these raw data were analysed by the indicators such as network centrality index, cliques, network density, block model, image matrix, MDS and QAP correlation, hierarchical regression in order to answer the research questions. Furthermore, this research is based on three analytical levels in social network analysis: “individual relationship”, “small group” and “global structure”, and not only explores the connection, power exercise and decision-making behaviour between these committee members but also analyses their role and position through the perspective of global network structure. The research verifies the hypothesis “decision-making is embeddeded in the structure of the actors’ interconnected social relationships” and utilizes the quantitative social network analytical method systematically to let network study go beyond a metaphor in the research field of public administration. I conclude that the distribution of the decision-making power and behaviour are both influenced by the committees’ social networks. Furthermore, the power distribution in the dental committee is two cores between the dental association and the BNHI, but the committee of Chinese Medicine is just one core of the Chinese Medicine association. With regard to attendance network as the independent variable, two factors significantly and positively influence the committee members’ attendance network: “decision-making influential network” and “resource exchange network”. Finally, the factors of “the NHI affair discussion network” and “the affair discussion clique centrality degree” have positive statistical significance but relatively the factors of “personal decision making influence” and “seniority” have negative statistical significance on the interviewees’ perception of the collective policy outcome.