中醫總額預算制度之研究—以共有資源管理的觀點

Abstract

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。\n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.\nSincere 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. \nIn 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\ncooperation 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.