就醫流向的長期變遷

Changing Patterns of Patient Flow: A Case of Taiwan's Health Care Delivery System

10.6288/CJPH1994-13-01-06

張苙雲(Ly-Yun Chang)；謝幸燕(Hsin-Yen Hsieh)

help-seeking behavior ； utilization of health care ； supply and demand of health care

中華公共衛生雜誌

13卷1期（1994 / 02 / 01）

54 - 76

繁體中文

本篇論文試圖處理兩個問題，第一是：台灣民眾的就醫流向的長期趨勢是什麼？第二是：由民眾的需求面來看，民眾集體所表現出來的就醫行為模式，尤其在區域上的流動和醫院級別之間的流向，在過去九年之間是否發生變化？利用衛生署之「傷病調查檔（簡稱），以七十八年之就醫流向模式做為結果，合併以過去八年（七十至七十七年）的就醫流向之發展，將各醫療區的九年的變遷圖像拼出。這個拼圖的形成，在考量醫療資源之絕對分佈變化的影響之下，比較著重於表達民眾就醫行動所傳達的主觀評估訊息，由於使用的是百分比的資料，因而所呈現出的結果是各區域間相對位置的變遷，是一個動態的模型。 本研究的主要發現有四：1)十七個醫療區可以依當地就醫和醫療機構的吸納能力分為「封閉型」、「開放型」、「吸納型」、和「匱乏型」等四種型態；2)以就醫當地化的指標為準，除了少數醫療區外，各區居民在當地就醫的比率普遍上揚，而且醫療區之間的平均差距逐年加大後，在七五年出現了明顯的轉折點而區域間平均差距開始縮小。3)各醫療區之醫療機構，集體的市場佔有率依各區而有所不同。值得注意的是醫療區間的平均差距的變化，雖然區域間的平均差距在七四年達到高峰之後，從七五年起已開始下降，但至七八年仍未回到七十年的水準。各區域醫療機構在住院市場上呈現的拉拒戰，因為醫療資源的改善而趨激烈。4)台灣地區各級醫療機構之間並未有自然形成的分化模式，一方面，醫學中心與區域醫院在疾病類的分佈缺乏明顯的差別，另一方面，各級醫院已逐年侵蝕了診所的門診市場，成了醫院診所之間彼此消長的局面。據此，我們檢討了醫療系統的績效。至於這些模式形成和變遷的原因以及理論上的意義，則在簡短說明後，由另文討論。

We intend to answer two questions in this paper: 1) What are the key features that characterize the patterns of patient flow over time in Taiwan? and 2) How does interregion health resource utilization and over-utilized higher level health resources differ according to different regions and different time periods? An analysis of the 1981-89 ”Morbidity Survey in Public and Private Hospitals/Clinics, Taiwan Area, ROC” collected by the Ministry of Health in Taiwan, four major findings were revealed: 1). Seventeen medical regions in Taiwan can be categorized into four major prototypes, namely close, open, ample, and scarce, in terms of two indecies: localization of health resource utilization and collective market share in local health market. 2). The level of localization of health resource utililization increased over time for most medical regions, however, average regional differences of the localization levels widened from 1981-1988 and narrowed after 1988. 3), Collective market shares in local health markets varied from region to region and between different points of time as well. In addition, average regional differences of the market share widened up until 1986 but never recovered to the level of 1981, indicating keener competition among hospitals of different medical regions. 4). A functional division of labor among different ranks of hospitals and clinics can not be observed over time. In general, hospitals have expanded their market shares at the expense of clinics in the outpatient market while medical centers and area hospitals have done so at the expense of others in the inpatient market. Medical centers have engaged in head-to-head competition with others, especially with area hospitals, in dealing with those diseases which don't require advanced treatments. We discuss the implications of these findings in an assessment of the effectiveness of the health delivery system in Taiwan over time. Issues raised in this descriptive study are outlined for further research.