THE ATTITUDE AND SERVICE CHANGES IN INSTITUTES OF MENTAL HEALTH CARE IN RESPONSE TOQUALITY-BASED PAYMENT SYSTEM

Abstract

目的：為了解各個精神醫療機構對論質計酬支付制度的態度以及各個構面與精神科醫療服務增減變化之間的關係。方法：本研究以台灣地區提供精神醫療服務之診所、醫院及精神復健機構為對象，以郵寄問卷方式收集下列資料：（一）對論質計酬的了解與支持程度，及精神醫療服務增減做調查（二）精神科論質計酬之態度之雙變項分析（三）精神醫療服務增減變項之邏輯斯迴歸分析，本研究之調查共抽取 267份樣本，回收166份，回收率62.1%。結果：研究結果顯示超過六成的受訪者認同健保局較易訂定精神科預算，並支持由健保局來適度訂定支付點數或金額。但亦有超過七成的受訪者認為該支付制度會造成機構間進一步的競爭與衝突，同時誘發醫師產生偏差行為，如此將更無法確保精神醫療的品質。至於實施此制度之後的精神醫療服務變化，超過半數的受訪者表示尚未想到如何因應；而已表示意見者大多以不變應萬變，即使有變化也是增加的項目多於減少的項目，且增加的項目以成本較低的服務項目為主（如：門診、日間病房、居家治療等）。社區精神醫療項目的設立在論質計酬制度影響之下，與「機構獲利考量」、「單位屬性」、「醫療機構層級」等項目有高度相關。結論：多數受訪者雖然支持健保局統一訂定支付制度，但對於論質計酬這樣的制度設計，高達七成的受訪者表示弊多於利。研究更進一步顯示，目前精神醫療界對論質計酬支付制度的實施普遍抱持觀望的態度，大多是不改變現在的精神醫療服務且對實施該制度後的經濟獲利情形採取較悲觀的態度。 Object: To analyze the relation between mental health institutes' attitude toward quality- based payment system and the change of mental health services. Method: This cross-sectional study was conducted by the same responders of the mental health institutes that provide mental health services. Author used questionaires to survey psychiatric rehabilitation institutions and psychiatric clinics in Taiwan. Author surveyed their attitudes and alterations of their services, I used bivariate analysis to analyze their attitudes and used logic regression to analyze the alterations of mental services. Author mailed 267 questionaires, 166 was returned and the response rate was 62.5%. Result: Their attitudes to quality- based payment system were pessimistic. More than 60% of responders thought that insurance unit can set appropiate money for services and set the psychiatry budget more easily . More than 70% responders thought that conflicts between institutes may happen and deviant behaviors may be induced. In general, most mental institutes havn't done any alteration in their services. If there is service volume changes, most of them prefer increasing their service items which cost lower such as OPD, day-care ward, and home visit services. Community service is related to institute profitability and institute level. Community psychiatry set up under quality-base payment system is related to institute profitability, institute level and institute belonging. Conclusion: About 70% of our responders thought that there are more disadvantages than advantages about the design of quality-based payment system. Furthermore, the majority of mental institutes haven't changed their service because of the change of payment system. Most of the responders were pessimistic to the profitability after the quality-based payment is started.