從患者就醫場所的選擇看轉診制度之落實

Abstract

本文依據臺灣封閉式醫療體系以及患者有就醫選擇自由的現況，設計一個兩階段的模型，描述患者、醫療院所雙方在健保制度下的互動，探討患者越級就醫或配合轉診的誘因。本文的研究結果顯示，封閉式醫療體系下，不同規模的醫院最終帶給患者的醫療效果有所差異，所以患者是考量醫院的行為、進而做出就醫場所的選擇。由於患者就醫場所的選擇除了考量成本面因素，亦同時受到效益面因素的影響，也就是不同醫院的治療效率。再者，本文也從患者選擇醫院規模的誘因看出，調整部分負擔僅能改變貨幣成本所形成的財務誘因，但無關乎不同醫院為患者創造的療效，所以，調整部分負擔的單一措施不見得能收到落實轉診的成效。在臺灣封閉式體系與就醫自由的先天條件下，落實轉診與分級就醫的目標，除了加重越級就醫的部分負擔，也可以由健保支付制度設計以及醫療院所整合等方面著手，給予基層醫療和醫院適當的財務誘因，進而有助於提高患者配合轉診的意願。

In Taiwan, the health care system is closed-form and non-gate-keeping. This study explained patients’ choices and practitioners’ referral according to a two-stage model. The results could show that a patient’s choice for hospitals or clinics depended on not only the co-payment, but also the benefit consideration. That was because hospitals and clinics in the closed-form system might provide services in different treatment efficiency. According to the incentives of patients’ choices, increasing the co-payment only changed the financial incentives, but it did not affect the treatment or benefit consideration. Under the closed-form and non-gate-keeping system in Taiwan, practitioner referral would be encouraged through the reform of insurance payment and the vertical integration between hospitals and clinics. Those could provide hospitals and clinics with financial incentives, and discourage patients’ self-refer.