總額支付及核減制度下醫院盈餘管理之研究：組織型態之差異

Earnings Management Behavior under the Global Budget Payment and Reduction of Medical Expenses System: The Effects of Different Types of Hospitals

本研究探討在健保總額支付及核減制度下，醫院組織型態對其盈餘管理行為之影響。本文運用中央健康保險署所公布之2013至2018年私立醫療機構、醫療財團法人、醫療社團法人財務報告，建立模型估計裁決性點值調整數、裁決性健保核減數，用以衡量各醫院之盈餘管理程度。實證結果顯示，當盈餘管理前之盈餘愈高時，私立醫療機構較醫療法人，提列較高之點值調整數及健保核減數，以調降盈餘。此可能係因私立醫療機構盈餘之多寡，直接影響負責醫師或合夥醫師須負擔之稅負，以及私立醫療機構之醫院治理機制較醫療法人較不完備所致。再者，本文亦發現，與醫療社團法人相較，醫療財團法人於盈餘管理前之盈餘愈高時，提列較高之點值調整數及健保核減數，以調降盈餘。此可能係因醫療財團法人為非營利醫院，被賦與的公益性較高，其結餘應提撥較高比例辦理研發、人才培訓、健康教育、醫療救濟與社區服務等事項，且為避免過高盈餘導致更多的監督與管理，而有較強動機調降盈餘。本研究延伸醫療機構盈餘管理的研究範圍，將醫療社團法人與私立醫療機構一併納入分析。本文進一步發現，在全民健保總額支付及核減制度下，國內醫療機構除了運用健保核減應計數外，亦運用裁決性點值調整數進行盈餘管理。最後，本研究結果可提供監管機關作為修正醫療機構治理政策，例如訂定醫療機構提列裁決性應計數之指引。

The current study examines earnings management behavior under the Global Budget Payment and Reduction of Medical Expenses System across various types of hospitals in Taiwan. Using 2013-2018 financial data available from the National Health Insurance Administration, this study builds models to estimate the discretionary accruals (e.g., float-point adjustment and allowance for National Health Insurance deduction) as proxies for earnings management behavior of hospitals. Our results of regression indicate that compared to medical juridical persons, private hospitals employ discretionary accruals to reduce income to a larger extent when pre-managed earnings are high. This is possibly due to that the income of a private hospital has to be combined with the personal income of the physicians in charge of the hospital for taxes to be levied. Furthermore, the hospital governance mechanism of private hospitals is less strict than that of medical juridical persons. Our results also show that compared with medical care corporations, medical care foundations use discretionary accruals to reduce income to a greater extent when pre-managed earnings are high. The possible reason for this observation is that medical care foundations, which are nonprofit hospitals, have incentives for mitigating excessive monitoring due to high earnings. This study contributes to the extant literature by also investigating the earnings management behavior of private hospitals and medical care corporations in Taiwan. The second contribution is that this study finds besides ＂allowance for National Health Insurance deduction,＂ hospitals also use discretionary ＂float-point adjustment＂ accruals to manage earnings. The findings from this study offer policy implications for regulators to consider revising the hospital governance policy, including providing guidance for hospitals to estimate discretionary accruals.