全民健保下的家庭醫師整合照護制度---竹東榮民醫院個案研究

Abstract

歷次民調顯示，民眾對全民健保的滿意度高達7成；根據英國Healthcare International季刊2000年的報導，27個主要國家中台灣名列最健康國家的第二名，獲得各國公共衛生專家的肯定。可是，我們的健保收入恐是各國中最低的。醫療支出占GDP的比重，美國最高，台灣跟南韓幾乎最低，台灣一年花在健保支出為5,616億元。醫療費用高並不表示整體醫療品質好，美國並沒有全民健保，被批評為浪費許多資源，又無法照顧窮人。一般認為加拿大與瑞典做得最好；而台灣因保費成長遠低於給付成長，帶來沈重的財務負擔，在開源（適度提高保費）與節流（減少浪費）方面都還要努力。 世界衛生組織早於1986年提出「健康促進」理念，即已揭櫫社區參與和社區醫療的重要性。我國政府雖於幾年前開始推動「社區健康營造」，但基層醫療資源的參與始終有限。台灣社會在經歷SARS洗禮之後，開始警醒社區團隊醫療的重要性，後SARS醫療體系重建計畫大規模推動「家庭醫師整合健康照護制度」，成立社區醫療群，結合開業醫師、醫院與公共衛生資源，搭建平行與垂直合作模式，建立以社區為導向、以家庭為單位、以病人為中心的全人健康照護模式；另一方面經由醫師教育改革，實施「畢業後一般醫學訓練」，推展社區醫學訓練。 成立社區醫療群推動家庭醫師制度計畫是行政院衛生署，為建構社區醫療體系之先導計畫；竹東榮民醫院於民國九十三年加入此計畫，並同時成立兩群社區醫療群。本計畫基本上應由下而上，由基層自行組成，再尋求合作的社區醫院。但在開辦時點，這樣做是不可能的，乃是由本院主導而成立計畫執行中心，設立共同照護門診，成立社區醫療群轉診中心、資訊中心，運作至今已近九個月，一般社區醫療群最常見的問題為二十四小時call center（電話諮詢）之執行，竹榮以最大的配合度，不計成本的以醫師排二十四小時call center班，使計畫順利推動，醫院與社區醫療群對於計畫實際的期待亦取得共識。藉由健保局對試辦專案的品質要求，進一步辦理「家戶座談」及「社區健康促進活動」，使地區醫院及診所醫師走入個案家庭，在社區成為真正的健康促進主導者，並激發對於社區居民照護的動力。 本論文乃報告家庭醫師整合性照護制度計畫補助款對醫院所帶來的經濟效益。雖然有形的計量成果十分有限，但對於不可經濟量化的效益是無窮的。

It is noted that National Insurance of Health (NIH) is well recived in Taiwan. According to an English Healthcare the International 2000 quarterly report, in 27 main countries Taiwan ranks the second among the healthiest nations. Due to the increases of co-payments and the financial burden of NIH, Taiwan suffers the degraded performance of her national health care systems. Taiwan government has started its community health program despite the limited basic unit medical service resources. The Taiwan society experienced the SARS epidemic and realized the importance of community medical team services. The community service includes local practice doctors, the hospital and the public health resources. Each family is treated as the basic unit. A patient is the center of health care moreover, this program helps the continued education of doctors. Tenable Community healthcare group integrates family physician the delivery health care plan that is arranged by the Department of health (DOH). Chutung veterans hospital joins this plan in 2004, and simultaneously establishes two groups of communities health care. This plan is basically built from bootom to top, voluntarily composed by the local doctors, then seeks for the cooperation of the community hospitals. The establishment of information center, setting up outpatient service of the community services was carried out by Chutung veterans hospital. This operation has already implemented for nearly nine months. This project contributed some economic efficiency which brings to the hospital, but the non-economical benefit could be very extensive.