| 摘要: | 本研究分為三個子題。第一個子題，我們針對全民健康保險實施後的台灣醫院產業做背景的介紹，並探討近年醫院產業型態變化所衍生的影響。而有鑑於醫院集團的趨勢日漸重要，第二個子題進一步討論醫院集團對醫療服務品質的影響，第三個子題則討論醫院集團對醫院生產技術效率的影響。 在子題一方面，台灣醫院產業在全民健保後有持續大型化的趨勢。醫院大型化背後的成因是受到中央健保局的支付方式、民眾的就醫習性，以及稅法提供的誘因所導致。在醫院大型化的發展方向下，可能衍生醫療資源配置的扭曲，以及使醫療層級分工無法發揮的問題。醫院集團是醫院大型化關鍵的影響因素。台灣醫院隸屬於集團體系的醫院家數約佔全國醫院的29%，但其總病床數佔全國醫院總病床數的份額卻高達60%。醫院集團佔有相當重要的地位，其對於醫療服務品質的影響以及對生產技術效率的影響，我們將延伸探討這兩個議題。 子題二，我們延伸Gaynor (2006) 的理論模型，並且加以實證來分析醫院集團對醫療服務品質的影響。就理論模型而言，當醫院集團者擁有規模經濟或成本節省的優勢，透過邊際成本的降低，有助於醫療服務品質的提升；但若醫院集團者面對競爭程度較低的環境，可能在醫療服務的提供有所鬆懈，導致其醫療品質的邊際成本提高，而不利於醫療服務品質的提升。實證結果顯示，醫院集團有助於醫療服務品質的提升。 在子題三方面，本研究利用O’Donnell et al.(2008) 資料包絡法的共同邊界分析架構，探討醫院集團對技術效率的影響，同時亦討論醫院集團是否為醫院達到共同邊界的技術水準與改善技術變動的影響因素。實證結果顯示，在技術效率方面，醫院集團對技術效率沒有顯著的影響，但在總額支付制度實施後，地區醫院為醫院集團者，有助於技術效率的提升。在共同邊界的分析架構下，醫院集團模式有助於醫院接近潛在的技術水準；此外，在分析技術變動方面，醫院集團對技術進步無顯著的影響，但在總額支付制度後，醫院集團者有助於技術進步。 This research includes three parts. In the first part, we give the general idea of the background of the hospital industry in Taiwan after the practice of NHI. Since multihospital system paly an important role in this industry, we analyze the impacts of multihospital system on medical service quality in our second part and on the production technical efficiency in our third part, respectively. In the first part, we find that the scale of hospital is getting larger, which is resulted from (1) the payment from Bureau of National Health Insurance based on Hospital Accreditation; (2) insurants’ medical behavior after the practice of NHI; (3) foundation hospital appearance with tax reduction. The development of large scaling hospital could distort the efficiency of resource allocation and cause the breakdown of division of hospital work. Furthermore, the multihospital system is also a key point of large scaling hospital. Although the multihospital system only takes 29% of the total number of the hospital in Taiwan, it takes 60% of the total hospital bed. Thus, we analyze the medical service quality and the production technical efficiency in multihospital system in part 2 and 3. In the second part, we study the effects of multihospital system on medical service quality. Based on the theoretical model (Gaynor 2006), we find that the multihospital system has the advantage of economic scale and cost-saving. The reduction of marginal cost helps the improvement of medical service quality. However, when it faces a less competitive market, the multihospital system might slack off in medical service, which increases the marginal cost of enhancing medical quality and decreases the medical service quality. The empirical results show that the operation of multihospital system helps to improve the medical service quality. In the third part, we adopt the metafrontier framework estimated with DEA (O’Donnell et al. 2008) to analyze the effects of multihospital system on technical efficiency. We also examine whether the multihospital system can help hospitals reach the technological level of metafrontier and improve the technical change. Our empirical results show that multihospital system does not have a significant effect on technical efficiency. However, after the practice of global budget system, the multihospital system of the local hospitals can improve technical efficiency. Under the analysis of metafrontier, we find that multihospital helps hospitals approach their potential production technological level. In addition, multihospital system has no significant effect on technological change. After the practice of global budget system, however, multihospital system can improve technology. |
