The Impact of Hospital-Based Global Budget on Emergency Departments

• Main Authors: Wei-Kung Chen, 陳維恭
• Other Authors: Pei-Tseng Kung
• Format: Others
• Language: zh-TW
• Published: 2005
• Online Access: http://ndltd.ncl.edu.tw/handle/81437872177047915057

碩士 === 臺中健康暨管理學院 === 健康管理研究所 === 93 === Hospital-based global budgeting (HBGB) is a newly introduced insurance policy in hospitals in Taiwan. The key purpose of HBGB is to control the increasing medical expenditure. However, hospitals who join the scheme lose the incentive to expand their services due to the fiscal restrictions imposed by the HBGB. This has had a considerable impact in most hospitals. As the gatekeeper of the hospital the emergency department is providing medical care at the frontline. It is therefore postulated that the impact of the HBGB was greatest in this department. The purpose of this study was to analyze the extent of the impact of the HBGB on EDs and ED staff in Taiwan. A structured questionnaire was created and sent to nurses and physicians at EDs. The content of the questionnaire included self-reported assessments based on a rating scale which measured the impact of the HBGB on the ED with regard to structure, process, outcome and overall satisfaction. The questionnaire also included questions about the strategies hospitals had adopted to cope with the restrictions of the HBGB. Descriptive analysis was applied to the rating of HBGB impact. Logistic regression analysis revealed that the independent variables were type of hospital, whether hospital joined HBGB or not, the level of hospital, duration of work in the ED, and job type (nurse or physician). There were 609 respondents (nurses and physicians) from 47 hospitals and 38 respondents (other hospital staff) from 38 hospitals. The HBGB mainly affected the EDs structure, process and outcome according to the nurses’ and physicians’ questionnaires. Most of the impact of the HBGB was related with the hospitals’ responses to the HBGB. The rating scales were significantly different between HBGB and non-HBGB hospitals, and among different levels and types of hospital. The impact of HBGB was greater in medical centers than in local hospitals (odds ratio=1.995, 95% CI 1.145-3.476). The impact of cost control was greater in HBGB hospitals compared with non-HBGB hospitals (OR=2.105, 95% CI 1.370-3.234). The impact on the process in EDs was 2.290 times greater in private hospitals than in public hospitals (OR=2.290, 95% CI 1.176-4.459) and 2.639 times greater in senior (≧10 years) than in junior (< 5 years) ED workers. Quality of care was 2.097 times lower in HBGB hospitals than in non-HBGB hospitals. In addition, 2.166 times more physicians than nurses considered the quality of care to have decreased. Furthermore, nurses or physicians who had worked at the ED for 5-10 years and 10 years were 1.790 times and 2.724 times than junior ED staff considered the quality of care to have decreased after implementation of HBGB. There were 3.144 times (95% CI 1.305-7.577) more staff aged under thirty years than those over forty who reported a greater willingness to change job or hospital after HBGB. The HBGB has had a considerable impact on EDs in Taiwan. Most of the impact had arisen from the hospitals’ responses to the HBGB. Health policymakers need to consider providing EDs with supplementary support, and must closely monitor the effects of the HBGB in order to maintain normal functioning of the emergency medical services. For the EDs, we advise that more effectiveness manpower utilization system have to apply to resolve the inadequate ED’s manpowever. Furthermore, using clinical guideline to shorten the waiting time and decrease the rish of legal problems. For the hospital administrators, ED’s manpower has to fit the increasing volume of patients. In addition, setting up a backup surveillience system to the ED is advised. For the BNHI, more effectiveness quality indicators are requirement. For the Department of Health, introducing a appropriate health insurance program is very importance. In addition, DOH have to seriously consider to adjust the NHI premium rate.