目標：本研究的目的旨在探討基層醫師在總額支付制度實施後對總額委員會管理制度的評價，包括同儕制約、提升專業自主性、保障執業收入、審查制度合理化、提升醫療品質、提升醫病關係等。另徵詢基層醫師對於高額折付以及醫院、基層之門診總額是否合併之意見。方法：本研究採取自行設計之結構式問卷，以92年2月23日為基準日，採用分層系統抽樣的方式自中部四縣市與健保局特約之1715家西醫診所抽取200家為研究對象，回收有效問卷144份，回收率為72%。結果：基層醫師對提升專業自主性、同儕制約、審查合理性、保障執業收入等策略的同意度較高；對於有提升醫療品質與醫病關係等策略的同意度與不同意各半。只有約半數的醫師贊成實施高額折付，卻只有不到二成的醫師贊成基層與醫院門診總額合併。結論：從本研究的結果可以發現，醫師團體較傾向於採取保護團體成員收入與專業自主性的策略，對於提升品質的策略較無法顯現。本研究建議醫師團體應逐步利用累積的資訊建立更完善的品質提升措施，並在點值逐步下降的時候思考如何在保障會員權益與提升效率中求取平衡點，以追求永續發展。

Objectives: The objectives of this study are to discuss the primary care physicians' evaluation of the impacts on physician organization following the implementation of the global budgeting system (including peer review, promoting professional autonomy, ensuring income, rationalizing the auditing system, improving quality of care, and improving the physician-patient relationship) and the agreement upon a discount for high-volume services and the budget combination between primary and hospital outpatient accounts. Methods: This study adopted the survey method of a self-designed structured questionnaire. It used the stratified systematic sampling method to select 200 western medicine clinics in central Taiwan from a total of 1715 clinics on February 23, 2003. Finally 144 valid responses were received with a response rate of 72%. Results: Results show that the agreement on the improvements in professional autonomy, peer pressure, rationality of utilization review, and secured income is relatively high. However, the agreement on the improving quality of care and improving the physician-patient relationship is relatively low. Half of the physicians agreed to adopt a discount for over-the-ceiling income physicians, but less than 20% of the physicians agreed with a lump sum budget combining the primary care and hospital outpatient sectors. Conclusions: This study found that physician organizations tend to adopt protective strategies rather than efficiency strategies for primary care global budgeting system. This study suggests that the physician organization should utilize accumulated information to build a more comprehensive quality improvement system, and try to reach a trade-off between ensuring member's interests and improving efficiency when reimbursement values progressively dropping.

總額支付制度 ； 醫師團體 ； 基層醫師

Global budgeting payment system, physician organization, primary care physician