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

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.

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.

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.