醫院內醫師報償契約設計－－代理、交易成本、資源依賴及制度理論之詮釋

Explaining Pay Contract of Physicians Using Agency, Transaction Cost, Resource Dependence and Institutional Theories

醫院與醫師交易主絡間，雙方存在部分目標衝突、風險偏好差異、資產 專屬性、成果不確定、資源依賴及健保制度壓力等問題，本文嘗試結合經濟 社會學中強調個體觀點的代理、交易成本與資源依賴理論，以及強調總體觀 點的制度理論等文獻，探討影響醫師報償基礎（固定薪與績效薪）的構念與 變頃，提出較其整合性分析。報償其約設計，涉及人性動機與情境變數等複 雜性，四種理論對於報償基礎選擇有其一致性及區別性的焦點，其中，代理 理論考量醫療任務可標準化程度、醫療行為可觀察性及成果可衡量性，並主 張最適契約須要求醫師分擔風險；交易成本分析醫院投入專屬性資產，使交 易風險提高，傾向以關條型契約抑制醫師的投機主義；根據資源依賴觀點， 醫院依賴醫師的才能、經驗、流動率等，調整固定與績效薪比率，亦需滿足 外部市場能提供醫師的淨獲利。代理、交易成本與資源依賴理論，偏重於任 務環境的經濟理性考量，個別醫院為契合自己總額目標，因而不同醫院之醫 師費有其差異性；然而，制度理論偏重制度環境的規範理性，主張醫院為尋 求正當性，因應支付制度的壓力， 跟隨其他醫院的行動，促使多數醫院的醫 師報償同形化。

The purpose of this article is to integrate and analyze key constructs related to agency, transaction cost, resource dependence and institutional theories on insight into pay contracts for physicians. These theories shown information asymmetry, level of uncertainty, high transaction-specific asset, dependence-resource relationship and institution stress in hospital-physician exchange provide a contribution to a hybrid contract- basis of the fixed and variable components, and are seen to be complementary. Regarding convergent and divergent focus from four theories and the implication of management are also discussed. We may conclude that integration of multiple perspectives may be better to explain the pay decision-making for physicians in hospitals. Further study should test the links between a broad set of variables explaining pay policy.