From the late 60's, there has been a huge increase in medical expenses in the US. The ratio of total medical expenses to GNP was nearly 14% in 1992. As a result, heavy burden was put on the country's economy. Similar financial impact can be felt by any country implementing health insurance. Hence, a lot of research was carried out, aiming to lessen such financial crises. When the Prospective Payment/Pricing System (PPS) based on DRGs bill was passed in the US in 1983, the method of payment changed from fee for service to PPS, and was then adopted by many other countries. This new payment method has encouraged the cooperative concept among hospitals, doctors and nurses. It is now evident that medical costs in Taiwan continue to rise sharply. According to the national health insurance scheme, DRGs will be used as the basis for in-patients payments. However, as we are lacking a satisfactory cost accounting system and the management of medical record classification is still not flawless, it is now planned that the method of Case Payment will be used when the system starts. To face the new payment system, medical specialists and hospital management personnel must cooperate closely to control medical cost, and at the same time maintain high quality of health care services. Policies and models proposed to achieve these objectives include standardization of concurrent and retrospective review. Important cores are the estalishment of profiles of medical doctors, the management of medical resources and structural reorganization. Research have shown that such policies are effective. Nevertheless, no one to date has combined all of these to formulate a single comprehensive model. This model includes the procedures involved in defining practice parameters and standards. It also examines the continue improvement in cost and quality control by concurrent and retrospective review. In addition, utilization review, application of doctors profile and continued education for medical practitioners are all parts of the model. With careful editing and compilation, this model is designed to be applicable and effective. Special attention is paid to ensure that the medical professionals are fully respected. The role of the management is to provide administrative support but not to interfere with any practices. Operational procedures for abnormal management, the purpose of which is for revision and discussion but not punishment, must be simple. Medical data analysis is an importnat domain in our model formulation. Information and system analysis experts are consulted to consider how to accomplish all the predetermined goals without increasing computer CPU workload substantially. As the model combines of all effective cost and quality control methods, we anticipate that the use of this simple effective managerial model will increase efficiency and productivity of a hospital.
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