美國的聯合執業

Group Practice in the United States

全民健保開辦之後，基層醫療急速的萎縮中，有鑑於此，行政院衛生署於民國八十七年六月再度公佈聯合門診的設置標準，希望經由聯合門診的設置，能對特續萎縮中的基層療注入新的契機。然而自衛生署重新公佈聯合門診的設置準備迄今已有三年餘，臺灣聯合執業（包括聯合門診及聯合診所）的數目卻還是不多，在全國9402家西醫診所中，登記為聯合診所的僅有248家。本文希望藉由介紹美國聯合執業的經驗，鼓勵台灣聯合執業的推行。美國從19世紀末期開始即有聯合執業的產生，最早使用聯合執業模式乃為明尼蘇達州Rochester的梅爾診所(Mayo Clinic)，至1994年為止美國已有19,478家的聯合執業，全美32%的醫師都有參與聯合執業。美國聯合執業的規模從3人至數千人不等，據1995年的調查顯示，46%的聯合執業均為3至4位醫師所組成。至於在科別方面，70%的聯合執業均為單一科別，但是多重科別聯合執業的平均醫師數目，則是單一科別的四倍。Burns等人指出聯合執業的普及即是重組美國醫學的兩股力量之一。聯合執業不只受醫師重視，許多大型醫療機構也將購買或是成立自己的聯合執業，並將之視為醫療整合是否成功的重要關鍵點，所以包括醫院在內的許多大型醫療機構都在籌組屬於自己的聯合執業，也使得更多醫師所扮演的角色，逐漸由傳統的老闆變成受人聘雇的員工。

The primary care has been shrinking since the implementation of National Health Insurance. Therefore, the Department of Health wish to encourage the establishment of group practice to stop the shrinkage of primary care in terms of the revised standards for group practice clrnics in 1998. However, it has been over three more years since the establishment of revised standards for group practice. The number of group practice was only 248 out of 9402 primary care clinics in Taiwan. The purpose of this article is to introduce the experience of U.S. group practice in order to encourage the implementation of group practice in Taiwan. The group practice appeared in the end of 19th century in U.S.. The first group practice was the Mayo Clinic in Minnesota. There were 19,478 group practice by 1994. 32% of pjysicians in U.S. were members of group practice. As to the size of group practice, the number of physicians ranged from 3 to over one thousand. According to the survey in 1995, 46% of group practice were composed of three to four physicians. With regard to specialty, 79% of group practices were single-specialty. But the number of physicians in multi-specialty group practice was as four times as those in single-specialty group practice. Burns et al. stated that the widespread of group practices was one of the two forces that reshaped the health delivery industry of U.S.. The group practice did not only interest physicians, but many health care organizations also regard whether to purchase or establish their own group practices as the critical point of success. Thus, many health care organizations including hospitals established their own group practices. This also changed the role of physician from traditional employer to employee under group practice.