摘要全民健保自民國八十四年開辦以來，已堂堂進入第十年了，雖然獲得多數民眾的肯定，但是無庸置疑的，這些年來病患至各醫療院所就醫卻也抱怨連連，全民健保真的是照顧到全民的醫療嗎？為何連醫師也得走向街頭示威抗議？「看診愈多、賠得愈多」是現在醫師們心中的痛，逐漸突顯全民健保十年來除了財務困境外，卻也衍發更多的討論與爭議。本研究透過結構式訪談以及問卷調查，試圖從醫師的角度瞭解目前所實施的健保總額支付制度，對醫病關係及醫療行為的影響，以及醫師的續留或轉科意向，這對醫師的激勵與工作滿意有其重要性，分別探討如下：1. 分析在健保實施後醫師醫療行為與醫病關係的改變，以實際瞭解對醫師所承受到的衝擊。2. 參考先進國家德國與加拿大之健保制度，並與台灣現行制度比較之差異。3. 研究醫師未來在選擇執業科別的趨勢，以提供管理者能制訂更合理的總額支付制度，避免少數科別膨脹或畸形的發展，以保障大多數科別醫師的權益，進而有效控制醫療費用，確保醫療服務品質及降低醫療資源浪費的目標。4. 以激勵理論探討醫師的工作滿足。在問卷結果中，發現樣本裡有12年以上的資深外科醫師，僅有31.58％願意留在外科，卻有高達42.11％想轉到眼、耳、皮科。即使資淺的外科醫師，也僅有53.33％願意繼續留在外科。使我們警覺到「醫師」這個曾經是大學聯考成績最好的才能考進，外加七年苦讀、嚴格的訓練才能養成的行業，他們的「工作滿足」是否已亮起了紅燈。健保制度在這個過程扮演什麼樣的角色？我們將把深度訪談的結果，套在激勵理論的架構加以探討，解析量化與質性訪談的研究發現，並試著使用「公平理論」、「工作特徵模式」、「社會訊息處理歷程」、「成就需求」四大理論加以解釋。關鍵字：總額支付、醫療行為、醫病關係、轉科意向、激勵理論 AbstractIt has been ten years since Taiwan’s NHI was implemented in 1995. Although NHI has brought the satisfaction to the majority, complaints from health providers and the insured have also surmounted as well. We have reasons to doubt weather NHI has covered well people’s health or not. Otherwise, why do the doctors have to go to streets to protest for their own rights? “To see more patients, to get less payments” is just one of the inequalities perceived by the doctors. Besides the possible financial debacles, disputes over the current NHI system have surfaced.This study intends to investigate doctors’ perception on NHI using in-depth-interview and Likert-scale questionnaire. We wish to find out the impact of NHI on doctors’ switching intention and job motivation, including:1. To analyze the change of medical behavior and doctor-patient relationship during the post-NHI era.2. To compare Taiwan’s NHI with German’s and Canada’s.3. To study doctors’ intention to switch among various departments and the implication of avoiding disputes and complications.4. To explore doctors’ job satisfaction using motivation theory.From the questionnaires, we found only 31.58% of the senior surgeons who had been practicing over twelve years intended to remain in surgical department. 42.11% of them wished to switch to the dermatology, ophthalmology or ENT. Only 53.33% of the junior surgeons who had been practicing less than twelve years intended to remain in surgical department. We investigate the role of the doctors under the impact of NHI and try to explain the results from perspectives of motivation theories, including equity theory, social information processing theory, job characteristics model and achievement theory.Key Words: global budget, medical behavior, doctor-patient relationship,switching intention, motivation theory.
