在健保局財務日漸困難又須照護全民民眾健康的使命下，如何讓健保資源充分發揮醫療照護責任是最重要的課題。透析預算在門診透析小總額的支付制度下，由於腎臟透析病患每年增加的速度超過總額費用成長的幅度，因此門診透析點值持續下滑在未來是必然會發生的狀況。由於腹膜透析的成本效益優於血液透析，但是台灣當前的透析治療仍是以血液透析為主。故本研究之主要目的在探討台灣地區腎臟照護醫療人員對於血液透析及腹膜透析的健保給付方式認知對其選擇透析模式的影響，在兼顧成本效益及透析醫療品質的前提下，進而調整現行選擇模式，適度提高腹膜透析比率，期能達成減緩門診透析點值滑落速度以及照護透析患者權益的雙重目標。
本研究先針對相關文獻進行整理，再透過問卷調查的方式蒐集資料，以探討醫護人員處方行為。大多數醫護人員最關心的是成本及利潤，本研究以統計方法探討醫護人員對健保給付之認知，並進而探討業務信任度與考量處方因素對處方行為之關係。
研究結果發現：（一）腎臟科醫療人員對透析治療健保支付制度及成本的認知正確度高者，選擇血液透析處方比例高於腹膜透析；（二）腎臟科醫療人員對腹膜透析治療銷售業務的信任度高低不影響對血液透析的處方選擇（三）醫護人員考量透析治療的給付價格及治療成本會影響處方選擇行為。

The financial status of BNHI is getting worst in recent years, however, their main mission is still to provide the health care for the Public. How to maximize the health care efficiency provided by the limited resources would be the most important task for BNHI.
Dialysis budget is designed as an overall capped budget by BNHI. Due to the increased rate of new ESRD patients is higher than the increased rate of total dialysis budget, the point value of outpatient dialysis will be continuingly decreased in the future. Although PD has better cost effective than HD, HD is still the majority of dialysis therapy used in Taiwan.The study purpose is to investigate the influence between health professionals’ general cognition on the Health Reimbursement payment scheme of PD and HD and their decisions on dialysis therapy options. On the premise that to keep the balance of dialysis care quality and cost effective, we suggest to adjust the dialysis therapy decision making model by moderately increasing the PD usage rate, which to achieve the goal of keeping the high quality of dialysis care and maintenance the point value of outpatient dialysis.
In this study, we focused on collaboration of relevant literatures in the first step, and conducted data collection by questionnaire survey for investigating prescription behaviors of healthcare professional . It revealed that most of healthcare professional concern about cost and profit . Therefore, we intended to investigate about cognition  of dialysis reimbursement and prescription behaviors between trust of sales representation and consider factor of prescription.
The study result revealed: (1)The professionals of nephron have right cognition of dialysis payment  and budget control, the prescription the HD  penetration rate higher than PD ; (2) The trust level on PD sales representative can’t influence the professional’s prescription for HD; (3) The professionals consider the dialysis reimbursement and cost effectiveness will influence the prescription behavior.

目	錄	I
表目錄	III
圖目錄	IV
第一章	緒論	1
第一節	研究背景	1
第二節	研究目的	5
第三節	研究流程	6
第四節	研究對象與研究範圍	6
第二章	文獻探討	7
第一節	國內外末期腎臟病(ESRD)概況	7
第二節	健保給付血液透析及腹膜透析的給付制度	7
第三節	醫護人員對業務人員信任度之影響處方程度	13
第四節	醫護人員處方行為影響之因素分析	19
第三章	研究方法	30
第一節	研究架構	30
第二節	研究假說	31
第三節	研究變數定義與衡量	35
第四節	研究設計	39
第五節	資料分析與統計方法	40
第四章  資料分析	42
第一節	樣本結構分析	42
第二節	問卷效度與信度分析	43
第三節	探索性因素分析	44
第四節	各構面之相關分析	46
第五節	迴歸分析	48
第六節	基本資料分析	51
第五章  結論與建議	55
第一節	研究結論	55
第二節	管理意涵	59
第三節	後續研究建議	60
第四節	研究限制	61
參考文獻	62
中文文獻	62
英文文獻	65
網站	72
附錄	73

表 2 1 健保醫療費用支付制度適用範圍及方式	8
表 2 2 門診透析點值一覽表	10
表 2 3 門診血液透析支付標準(2011)	12
表 3 1 衡量醫師對腹膜透析銷售業務的看法之相關問項	36
表 3 2 衡量醫師對藥物考慮因素之相關問項	38
表 3 3 問卷抽樣方式	39
表 4 1 樣本基本資料統計表	42
表 4 2 各構念探索性因素分析結果	44
表 4 3 各構面之相關分析表	46
表 4 4 處方考慮各因素之相關分析表	47
表 4 5 迴歸分析結果	49
表 4 6 迴歸分析結果	51
表 4 7 階層職級對處方行為的選擇影響 ANOVA表	52
表 4 8 服務地區對處方行為的選擇影響 ANOVA表	52
表 4 9 服務的醫院層級對處方行為的選擇影響 ANOVA表	52
表 4 10 服務的單位特性對處方行為的選擇影響 ANOVA表	53
表 4 11 健保給付認知高低組對處方行為的選擇影響 ANOVA表	53
表 4 12 健保給付認知高低組對各構面的影響 ANOVA表	54
表 5 1 假說驗證結果	55

圖 2 1 第三者代購人決策模式(Hollander and Rassuli ,1999)	15
圖 3 1 研究架構	30

中文文獻
1.王崇禮(2006)。台北市某醫學中心主治醫師績效獎勵金制度之研究。國立台灣大學商學研究所碩士在職專班高階公共管理組。
2.史懷哲(1998)。績效獎金制度與醫院非醫師員工工作表現及滿意度關係之研究－以台北某教會醫院為例。國立台灣大學公共衛生學院醫療機構管理研究碩士論文。
3.吳明隆(2003)。「SPSS統計應用學習事務：問卷分析與應用統計」。台北：知城數位科技公司。
4.吳銘標(1988)。醫師ＰＰＦ制度之研究。碩士論文。
5.吳鍇(2011)。社會網絡對於心理契約認知之影響分析。Journal of Management，28(1)，49-63。
6.李奇樺、朱國光(2012)。關係連結對挽回流失顧客影響之研究-以零售服務業為例。管理學報 第29卷第1期，45-60。
7.佘炎輝(2004)。健保醫療費用核刪分析與其BPR之研究-以某醫學中心為例。 國立成功大學工學院工程管理碩士在職專班碩士論文。
8.卓佳慶、劉順仁、James C.Romeis(2012)。醫療服務品質與財務績效：台灣血液透析診所的實證分析。Journal of Management，29(1)，61-80。
9.梁瓊慧、楊勤熒、盧國城、朱柏齡、陳瓊華、謝湘俐、周桂如(2008)。慢性腎臟疾病患者選擇腹膜透析模式影響之因素。臺灣腎臟護理學會雜誌 第7 卷第2 期。
10.周麗華、劉雪娥（2003）。長期腹膜透析病患性問題及相關性因素探討。臺灣腎臟護理學會雜誌，2（2），129-142。
11.林佳燕(2009)。血液透析與腹膜透析病患之長期醫療成本分析。台灣大學醫療機構管理研究所學位論文。
12.林明桂(2002)。健保總額預算支付制度下主治醫師薪資設計之研究 ─ 以東部某區域醫院為例。國立東華大學企業管理研究所碩士論文。
13.邱皓政(2010) (第五版)。量化研究與統計分析。台北：五南圖書公司
14.施智婷(2012)。領導成員交換關係、心理契約滿足與組織公民行為理論模型驗證：資源配置與社會資本觀點。Journal of Management，29(1)，1-16。
15.柯雨利(2003)。促銷活動對醫師藥物選擇行為之影響。國立成功大學管理學院高階管理碩士在職專班(EMBA)碩士論文。
16.常逸平、錢慶文、楊耿如(2007)。全民健康腹膜透析比血液透析省錢嗎?台灣衛誌第26卷第五期，400-408。
17.康志鵬、張宗興、江守山（2002）。腹膜透析在糖尿病末期腎病變之運用‧腎臟與透析，14（2），70-74。
18.張錦文(1996)。台灣醫師費制度沿革，醫師費制度國際研討會。長庚紀念醫院。
19.莊逸洲、黃崇哲(2000)。醫療機構人力資源管理，華杏出版股份有限公司，305-413。
20.陳志翔(2011)。銷售人員屬性、信任、顧客滿意度與購買意願關係之研究－以信任與顧客滿意度為中介變數。南華大學企業管理系管理科學碩士論文。
21.游麗穎(2010)。血液透析與腹膜透析之成本分析與管理：作業基礎方法之應用。國立台灣大學醫療機構管理研究學系碩士論文。
22.黃志杰(2006)。影響消費者對健康食品購買行為之研究。國立東華大學企業管理研究所碩士論文。
23.黃鉯喬(2009)。以「關係承諾—信任」理論探討供應鏈中夥伴關係之研究—以高科技產業為例。中華大學資訊管理學系碩士論文。
24.楊志良、劉順仁、朱炫璉(1999)。國內綜合醫院管理控制制度實施現況及成效的研究，會計研究月刊，第161期，115-118。
25.楊宗盛(2009)。不同透析方式之成本效果分析。中國醫藥大學醫務管理學研究所碩士班學位論文。
26.葉俊佑(2004)。健保藥品給付價格對門診口服降血糖藥品處方型態的影響。靜宜大學企業管理研究所碩士論文。 
27.樊一平(2007)。藥品行銷組合策略與醫師處方行為之關聯性研究。國立中正大學管理研究所 EMBA碩士論文。
28.蔣曉秋(2002)。影響醫師處方藥品的重購意願之探討。義守大學管理科學研究所碩士論文。
29.蕭婉婷(2007)。供應鏈夥伴間信任與承諾對更應鏈績效的影響。
30.謝敦仁(2006)。影響醫師處方行為之因素探究。淡江大學企業管理學系碩士在職專班學位論文。
31.藺汝平(2007)。台灣地區腎臟專科醫師對於末期腎病患者選擇透析模式的影響因素之看法。國立陽明大學醫務管理研究所碩士論文。
 
英文文獻
1.Baron,R.M.,& Kenny,D.A.(1986).The moderator-mediator  variable distinction in social psychological research: Conceptual,strategic,and statistical consideration. Journal of Personality                                    and  Social  Psychology, 51(6), 1173-1182.
2.Berry, L.L. (2000).Cultivating Service Brand Equity, Journal of Academy of Marketing Science, Vol.28, No.1, 128 - 137.
3.Bitner, Mary Jo.(1995).Building Service Relationships: It's All About Promises, Journal of the Academy of Marketing Science 23 (Fall),246-251.
4.Chaudhuri, A. & Holbrook, M.B. (2001).The Chain of Effects from Brand Trust and Brand Affect to Brand Performance: The Role of Brand Loyalty, Journal of  Marketing, Vol.65 (April), 81-93.
5.Coyle-Shapiro and Kessler,J.I.,(2003).The Employment Relationship in the U.K Public Sector:A Psychological Contract Perspective,Journal of Public Administration Research and theory,13(2),213-230.
6.Creyer and Hrsistodoulakis (1998).Marketing pharmaceutical products to physicians. Sales reps influence physicians' impressions of the industry，Marketing Health Services,Vol.18,No.2,34-38.
7.Crosby, L.A., Evans, K.R. & Cowles, D. (1990).Relationship quality in services selling: an interpersonal influence perspective, Journal of Marketing, Vol.54, No.3, 68-81.
8.De Vecchi, A.F., Dratwa, M., & Wiedemann, M.E. (1999). Healthcare systems and end-stage renal disease (ESRD) therapies – an international review: costs and reimbursement /funding of ESRD therapies. Nephrology Dialysis  Transplantation, 14(Suppl. 6):S31-S41.
9.Deepak Sirdeshmukh,Jagdip Singh and Barry Sabol(2002). “Consumer Trust, Value, and Loyalty in Relational Ex- changes,” Journal of Marketing, 66 (January), 15-37.
10.Doney, P.M. & Cannon, J. P. (1997). An Examination of the Nature of Trust in Buyer-Seller Relationships, Journal of Marketing,Vol.61(April),35-51.
11.Dwyer,Paul H. Schurr,and Sejo Oh(1987).Developing Buyer-Seller relationships, Journal of Marketing,51(April),11-27.
12.Fenton, S.S., Desmeules, M., Copleston, P., Arbus, G., Froment, D., Jeffery, J., et al. (1995).Renal replacement therapy in Canada: A report from the Canadian Organ Replacement Register. American Journal of Kidney Disease, 5:134-150.
13.G. Ardine de Wit, Paul G. Ramsteijn, Frank Th. de Charro(1998). Economic evaluation of end stage renal disease treatment, Health  Policy,vol.44 ,Mar,215–232.
14.Garbarino, E. & Johnson, M. (1999).The different roles of satisfaction,trust and commitment in customer relationships, Journal of Marketing,Vol.63, 70- 87.
15.Gefen, D, Karahanna, E & Straub, DW (2003), “Trust and TAM in Online Shopping”: An Integrated Model', MIS Quarterly, vol. 27, no.1, pp.51-90.
16.Gefen, D. (2002).Reflections on the Dimensions of Trust and trustworthiness among Online Consumers, Database for Advances in Information Systems, Vol.33, No.3, 38-53.
17.Gokal, R. et al. (2002). What is the evidence that peritoneal dialysis is underutilized as an ESRD therapy? Seminars in Dialysis,15:149-161.
18.Gonul, Fusun F.,Franklin Carter, Elina Petrova and Kannan rinivasan (2001).“Promotion of Prescription Drugs and Its Impact on Physicians` Choice Behavior,” Journal of Marketing, Vol. 65, July, pp. 79-90.
19.Granrose,C.S. and Baccili,P.A.,(2006).Do Psychological Contracts include Boundrayless or Protean careers?, International career development,11(2),163-182.
20.Hair, Jr. Joseph F., Anderson, R.E., Tatham, R.L. & W.C Black(1995). Multivariate data analysis, “3rd ed.,N.Y.: Macmillan Publishing Company.
21.Hollander,Stanley C.and Rassuli Kathleen M.(1999).“Shopping with other people’s  money”：The Marketing management implications of surrogate-mediated customer decision Making”,Journal of Marketing 63(2):102-18.
22.Hollander, Stanley C. and Kathleen M. Rassuli(1999). "Shopping with Other".
23.Jacobs, R., Hyman, Mr. & Mcquitty, S. (2000).Exchange specific self disclosure, social self disclosure and personal selling, Journal of Marketing,8-62.
24.Jap,Sandy D.(2001).The impact of online reverse actions on buyer-supplier relationships.Working paper.Emory University.
25.Jassal, S.V., Krishna, G., Mallick, N.P., &Mendelssohn, D. C. (2002). Attitudes of British Isles nephrologists towards dialysis modality selection: A questionnaire study. Nephrology Dialysis Transplant,17(3), 474-477.
26.Johnson, R.J., & Feehally, J. (2000). Comprehensive clinical nephrology. London: Mosby.
27.Kennedy, S.P., Ng, W.V., Salzberg, S.L., Hood, L. & DasSarma, S. (2001).Understanding the adaptation of Halo bacterium species NRC1 to its extreme environment through computational analysis of its genome sequence, Genome Res, Vol.11, 1641-1650.
28.Lagace, R.R., Dahlstrom, R. & Gassenheimer, J.B. (1991).The Relevance of Ethical Salesperson Behavior on Relationship Quality: The Pharmaceutical Industry, Journal of Personal Selling and Sale Management, Vol.11, No.4, 39-47.
29.Lundin, Douglas(2000).Moral Hazard in Physician Prescription Behavior, Journal of Health Economics, Vol. 19, 639-662.
30.Mayer, R.C., Davis, J.H. & Schoorman, F.D. (1995).An Integrative Model of Organizational Trust, Academy of Management Review, Vol. 20, No. 3,709-734.
31.Mendelssohn, D.C., Blake, P.G., Burkart, I., Golper, T., & Oreopoulos, D. (2001). Dialysis modality distribution in the United States. American Journal of Kidney Disease,37:1330-1331.
32.Mishra, A.K. (1996).Organizational responses to crisis: The centrality of trust, In R.M. Kramer & T.R. Tyler (Eds.), Trust in Organizations: Frontiers of Theory and Research. Thousand Oaks, CA, USA: Sage,261-287.
33.Morgan, Robert M. and Shelby D. Hunt . (1994).The Commitment-Trust Theory of Relationship Marketing, Journal of Marketing, Vol.58, No.3, pp.20-38.
34.National Kidney Foundation Dialysis Outcome Quality Initiative. (1997). Clinical practice guidelines for peritoneal dialysis adequacy. American Journal of Kidney Disease,30(Suppl. 2):S70-S73.
35.Nissenson, A.R., Prichard, S.S., Cheng, I.K.P., Gokal, R., Kubota, M., Maiorca, R. et al.(1993). Non-medical factors that impact on ESRD modality selection. Kidney International, 43(Suppl. 40):S120-S127.
36.Njite, D. & Parsa, H.G. (2005).Structural equation modeling of factors that influence consumer internet purchase intentions of services, Journal of Services Research, Vol.5, No.1, 43-59.
37.P.M. Doney, & Cannon, J.P. (1997). An Examination of the Nature of Trust in Buyer-Seller Relationships, Journal of Marketing, Vol.61,35-51.
38.Patricia M. Doney and Joseph P. Cannon(1997). An Examination of the Nature of Trust in Buyer-Seller Relationships. The Journal of Marketing. Vol. 61, No. 2, 35-51.
39.Paul M.Just,Frank Th.de Charro,Elizabeth A.Tschosik,Les L.Noe,Samir K.Bhattacharyya,Miguel C.Riella.(2008).Reimbursement and economic factors influencing dialysis modality choice around the world,Nephrology Dialysis Transplantation,Vol .23,issue. 7,2365-2373.
40.Peter C. Coyte , Linda G. Young , Brenda L. Tipper , Victoria M. Mitchell , Phyllis R. Stoffman , Janet Willumsen , Denis F. Geary , FRCPC.(1996).An economic evaluation of hospital-based hemodialysis and home-based peritoneal dialysis for pediatric patients, American Journal of Kidney Diseases Volume 27, Issue 4, April , 557-565.
41.Reichheld, F. & Schefter, P. (2000). “E-Loyalty,“ Harvard Business Review, 78(4): 105-114.
42.Rousseau,D.M.(1995).Psychological contracts in organizations: Understanding written and unwritten agreements. Newbury Park, CA: Sage.
43.Scharitzer, Dieter and Harald C. Kollarits (2000).“ Satisfied Customers:Profitable Customer Relationships”: Pharmaceutical Marketing: How Pharmaceutical Sales Representatives Can Achieve Economic Success Through Relationship Management with Settled General ractitioners-an Empirical Study,” Total Quality Management, Vol. 11, No. 7, 955-65.
44.Shamdasani, P.N. & Balakrishnan, A.A. (2000). Determinants of Relationship Quality and Loyalty in Personalized services, Asia Pacific Journal of Management, Vol.17, No.3, 399-422.
45.Singh, Jagdip and Deepak Sirdeshmukh (2000). "Agency and Trust Mechanisms in Relational Exchanges." Joumat of the Academy of Marketing Science. 28 (Winter). 150-67.
46.Spears, N. & Singh, S.N. (2004). Measuring Attitude toward the Brand and Purchase Intentions, Journal of Current Issues and Research in Advertising, Vol.26, No. 2, 53-66.
47.Swan John E.and Johannah Jones Nolan(1985).Gaining customer trust：A Conceptual Guide for the salesperson,Journal of Personal Selling&Sales Management,5(2),39-48.
48.Swan, John E., Trawick, I. Fredrick Jr., Rink, David R., and Roberts, Jenny: Measuring Dimensions of Purchaser Trust of Industrial Salespeople. Journal of Personal Selling & Sales Management 8 (May1994): 20–38. 1988): 1–9.
49.Tapani  Salonen, Tuomo Reina , MSc, Heikki Oksa, Harri Sintonen , Amos Pasternack.(2003). Cost analysis of renal replacement therapies in Finland, American Journal of Kidney Diseases,Volume 42, Issue 6, Dec, 1228-1238.
50.Tenery, Robert M. (2000).“Interactions Between Physicians and the Health Care Technology Industry,” The Journal of the American Medicine Association,Vol. 283, No. 3, January, 391-93.
51.Venkataraman, V., & Nolph, K.D.(1999). Socioeconomic aspects of PD in North America:Role of non-medical factors in the choice of dialysis. Peritoneal Dialysis International,19(Suppl. 2): S419-S422.
52.Wazana, Ashley (2000). “Physicians and the Pharmaceutical Industry: Is a Gift Ever Just a Gift?” The Journal of the American Medicine Association, Vol.283, No. 3, January, 373-80.
53.Weber, R. P. (1990). Basic Content Analysis, 2nd ed. Newbury Park, CA.
54.Wray, Barry, Adrian Palmer, and David Bejou (1994). "Using neural network analysis to evaluate buyer-seller relat," European Journal of Marketing, 28 (10), 32.
55.Zeithaml, V.A., Berry, L.L. & Parasuraman, A. (1996). The Behavioral Consequences of Service Quality, Journal of Marketing, Vol.60, No.2,31-46.
56.Zhao, L.,J, and Wang, T. (2003). Attitudes of Chinese chief nephrologists toward dialysis modality selection. Advances in Peritoneal Dialysis, 19:155-158.

網站
1.財團法人中華民國腎臟基金會（2007）。台灣地區透析病患年度報告。係於2011年6月27日查詢所得資料。
2.台灣腎臟醫學會http://www.tsn.org.tw/。係於2011年11月27日查詢所得資料。
3.台灣腎臟基金會（2007）。96年度台灣地區透析總人數。http://www.kidney.org.tw/a96.gif。係於2010年6月27日查詢所得資料
4.中央健保局http://www.doh.gov.tw/statistic/data。係於2010年6月27日查詢所得資料。
5.中央健保局。全民健康保險醫療費用支付標準(2011)。係於2011年9月20日查詢所得資料。
6.行政院衛生署中央健保局(2011)。門診透析獨立預算執行概況。係於2012年3月7日查詢所得資料。
7.U.S. Renal Data System (2007). USRDS 2007 Annual Report. from http://www.usrds.org/。係於2010年6月27日查詢所得資料。
8.U.S. Renal Data System(2011).USRDS 2009 Annual Report.
9.USRDS (United States Renal Data System) http://www.usrds.org/reference。係於2011年12月7日查詢所得資料。