大環境的改變、少子化的關係、兒童用藥安全的議題、中部基層診所實施科總額及月休四日的管理政策、基層小兒科執業受到別科強烈競爭、全國預防注射政策調整造成自費疫苗空間減少及兒童健康檢查政策改變等等，使得基層小兒科診所經營越來越困難。有鑑於此，希望藉由此研究了解基層小兒科診所經營上之特點，給基層小兒科診所負責人提供參考及建議；並探討目前基層小兒科診所經營困難，以提供台灣兒科醫學會努力的方向，亦可讓政府有關單位和中央健保局更了解基層小兒科診所經營的困難，作為未來制定基層小兒科醫療政策的參考。問卷題目為基層兒科經營困難之探討，調查對象為基層小兒科診所負責醫師，基層小兒科診所名單是經由行政院衛生署中央健保局網站取得，搜尋對象是診所設立時以小兒科為命名之診所，如此才能確定此診所之負責人具有小兒科專科醫師。此對象對問卷的問題所回答的內容，較能代表基層診所經營上之困難。經搜尋整理後，所有符合之診所約為1031家，回收份數241。執業的性別以男性居多女性只佔少部分，男生約佔92.5%，女生只有6.6%；小兒科醫師平均年齡為52.5歲，最小的年齡是32歲，最大的年齡是85歲；以執業場所依健保分區來看，調查回收比例以中區為最高佔26.1%，最少是東區只有1.2%；問卷結果中顯示診所有雇用醫師(包括合夥與僱傭關係)的比例佔29.8%；醫師開業前有被雇用過(包括合夥與僱傭關係)佔27.4%；以開業多久來看平均是16.4年；有耳鼻喉科治療台設備做局部處理佔了66.8%；男性自認為有經營管理的能力的比例比女性高；近五年內有無醫療糾紛(起訴、調解、和解)比例佔5.8%；有兼看成人慢性病(高血壓、糖尿病、痛風、高血脂)、戒菸或醫美減肥的項目的診所比例是70.1%；每月醫療申報中簡表申報比例平均為79.3%；診所負責醫師每個人週休平均值為1.08天；診所每週週休平均天數亦為1.08天；診所內自聘藥師佔71%；本問卷的調查中每月平均看診人次在2000人以下佔69.9%。從第二部分經營困難敘述性統計的結果中，可以發現問卷大部分的問題，非常同意跟同意都在七成以上。但對於兒童健康檢查由九次降為七次，是否造成經營困擾？非常同意跟同意只有55.2%；身為兒童的守門員，且是兒童家庭醫師，兒科專科醫師訓練知識及能力去面對基層多樣疾病的護理，是否造成您的壓力？非常同意跟同意更只有48.7%。問卷中有三題回答非常同意大於50%有：(1)對於藥物簡表申報假若改成實報實銷，是否造成經營困擾？(2)目前健保總額給付下，是否造成經營困擾？(3)少子化是否造成門診量減少？負責醫師開業前有被雇用過的診所會比醫師開業前沒有被雇用過的診所每月平均就診人數平均約多780人次，至於被何種科別診所雇用並沒有統計上差別。將診所開業幾年分成兩組，一組是15年以下(含15年)和另一組是15年以上，開業15年以上的看慢性疾病、戒菸或醫美減肥自費項目的比例較高、診所每月平均就診人次數較低、較少醫療糾紛、使用耳鼻喉科治療台設備且做局部處理的較低。診所有耳鼻喉科治療台設備做局部處置比沒有耳鼻喉科治療台設備做局部處置，在每月平均就診人數較多約為735人次；在診所負責人沒有被其他診所雇用過的情況下，有耳鼻喉科治療台設備且做局部處置會比沒有的，每月平均就診多約635人次；診所的負責人有被其他診所雇用過，且有耳鼻喉科治療台設備做局部處置其診所比兩者都沒有者，每月平均就診人次約多1250人次。根據上述的研究，建議小兒科醫師若要到基層開業能成功，開業之前要有受雇於其他診所之經驗；且診所最好備有耳鼻喉科治療台設備且做局部處置，如此可以增加每個月診所平均就診人次。至於基層小兒科診所經營困境方面，健保總額給付下及少子化是小兒科診所負責人最大的執業壓力，有待相關單位重視；並建議中央健保局考慮到小兒科診所經營的困難不應取消藥物簡表申報。 Modern Taiwan pediatric clinics are facing business difficulties due to low birth rate, severe competition in the medical services, and unjustified claim policies from the government. The purpose of this research is to investigate the difficulties of running a pediatric clinic in Taiwan, so more justified policy and managerial advices can be delivered to the government and clinics, respectively.Questionnaires with Likert items were mailed to the total 1031 pediatric clinics for the whole nation. Medical doctors in charge of the clinics were invited to answer the questionnaires. 241 questionnaires were collected. T test, Chi-square test, and ANOVA were applied in SPSS to analyze the data.The males are the majority in practice (about 92.5%); female gender accounted for only a small part (about 6.6%). Pediatrician average age is 52.54 years old; the youngest is 32 years old and the oldest is 85 years old. To the location of the practice, the highest percent of the received surveys from central region is about 26.1% and the lowest is from the eastern (only 1.2%). Questionnaire shows that 29.8% of the clinics have more than one physicians; 27.4% of the in-charge physicians were employed or partner physicians before running their own clinics; the average year of practicing is 16.4 years; 66.8% of the clinics have ENT (ear, nose, and throat) treatment device; 5.8% of the clinics were with medical disputes (prosecution, mediation, conciliation) for the last five years; 70.1% of the clinics also care adult chronic diseases; physician’s weekend off is an average of 1.08 days; about 71% of the clinics employ pharmacists.Seventy percent of the clinicians agreed the stress in running the pediatric medical services. However, the agreement percentages on the questions regarding their stress in caring illness were around 50%.The results also indicate an increase of 780 patients if the in-charge physicians were employed or partner physicians before running their own clinics. Clinic performances were analyzed by the opening years of the clinics (less than 15 years vs. more than 15 years). For clinics of more than 15 years, they care more adult chronic diseases; less of them were with ENT treatment devices; they are with a smaller number of patients per month.This is the first research dealing with the management issues for pediatric clinics in Taiwan. It is found that ENT treatment devices and employed/partner experience of the in-charge physician are critical success factors for the clinics. Low birth rate has brought influential pressure to the pediatric clinicians. Most of the clinicians suggest continuing using the current claim policy. The findings are important for the Pediatric Association in delivering the continuing education for clinicians, and for government when designing the claim policy.
