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1921.356, \"end\": 1921.597, \"score\": 0.914}, {\"word\": \"性\", \"start\": 1921.597, \"end\": 1921.797, \"score\": 0.948}, {\"word\": \"的\", \"start\": 1921.797, \"end\": 1921.957, \"score\": 0.744}, {\"word\": \"唯\", \"start\": 1921.957, \"end\": 1922.397, \"score\": 0.881}, {\"word\": \"獨\"}, {\"word\": \"一\", \"start\": 1922.397, \"end\": 1922.558, \"score\": 0.707}, {\"word\": \"再\", \"start\": 1922.558, \"end\": 1922.718, \"score\": 0.748}, {\"word\": \"的\", \"start\": 1922.718, \"end\": 1922.818, \"score\": 0.76}, {\"word\": \"宣\", \"start\": 1922.818, \"end\": 1923.098, \"score\": 0.871}, {\"word\": \"誓\", \"start\": 1923.098, \"end\": 1923.359, \"score\": 0.926}, {\"word\": \"而\", \"start\": 1923.359, \"end\": 1923.539, \"score\": 0.983}, {\"word\": \"已\", \"start\": 1923.539, \"end\": 1923.559, \"score\": 0.988}, {\"word\": \"謝\"}, {\"word\": \"謝\"}], \"language\": \"zh\"}","srt":"1\n00:00:04,106 --> 00:00:07,387\n謝謝主席我們是不是請邱部長委員好部長好今天大家談了很多這個急診詠攝和護理人力的問題但我今天還是要繼續講這個\n\n2\n00:00:25,726 --> 00:00:41,434\n大家都在談說這個病房護病比的限制護理人力的不足導致醫院這個關病房然後急診的住院帶床病人滯留狀況加劇那上次我也就教於你就是說光是減傷第一級的\n\n3\n00:00:41,954 --> 00:01:08,095\n他的平均的流治的時間都超過標準時間8小時的還要到雙倍以上那我現在就請你看一個圖到底我們這個護理人力你對於平均媒體報導這個護理人力平均年齡39歲資深護理師留任這個健校你們自己是這樣講留任健校你是怎麼看待這個資訊的\n\n4\n00:01:11,670 --> 00:01:28,445\n我是請那個市長先回答一下我是叫你看安安就是這樣講你自己發布的新聞你們自己的這個你自己都沒看過嗎就是說啊這個2024因為這個時候我還沒上任所以我要仔細看一下這樣子\n\n5\n00:01:29,926 --> 00:01:47,137\n不是啊這是前幾天5月去年5月13號的新聞你還沒上任好那你知道這個議題也應該要了解一下吧因為我當然是希望護理師生能夠留任不是啦現在從一路早上大家問你都覺得說\n\n6\n00:01:49,178 --> 00:02:06,031\n離職的雖然很多但你們12項政策要求穩定而且已經有見效增加的人力其實都是增加的雖然有離職的但你們剛才司長一直在講說人力普遍上還是增加的從你們的職登統計都看得出來那你們現在看出來數據我告訴你2021年護理師職業的平均年齡是36.95歲2024年是39.25歲\n\n7\n00:02:17,879 --> 00:02:39,435\n那我就這樣子問你就好了就這件事情啦職業的平均年齡越來越增加你怎麼看待這一件事情平均職業年齡提高啊你怎麼看啊這可能要從兩個角度嘛\n\n8\n00:02:42,048 --> 00:03:00,898\n因為當初去年你們認為這個是肯定把資深的留下來從這個角度來看也許是好事情那是不是說年輕的留不住也是一件事情這個可能要來看評但我們也很好奇為什麼年輕的因為我們開設多元的人才人力的培養\n\n9\n00:03:01,718 --> 00:03:22,436\n包括學社後的護理系有持續的開設而且包括護理師的考試從一年兩次變成一年三次但我們的平均職業年齡卻節節攀升那你講的你也講了就是說啊這個留不住年輕的專業的護理人力那你知道部長你知道2012年台灣護理人員平均職業年齡是幾歲嗎2012年\n\n10\n00:03:31,962 --> 00:03:40,613\n2012年啦你猜猜看你用猜的啦你們沒數據啦你用猜的你猜猜看好那多少歲被你偷看到了2012年29.6歲2024年39.25歲\n\n11\n00:03:50,520 --> 00:03:54,883\n當時2012年2012年離現在並沒有很久你們專案報告是說平均年齡29歲而且21到30歲族群最多佔了43.6%43.6%都是30歲以下的護理人力而現在30歲以下護理人力可能是\n\n12\n00:04:14,895 --> 00:04:31,866\n低的不像樣那你對這個數字其實你都沒有掌握我剛剛問你你也搞不清楚到底我們要肯定平均年齡39歲是留任成功還是說我們要擔心如果2012年平均年齡29歲2024年平均39歲如果照這個邏輯到2036年平均職業年齡會不會變成49歲有沒有可能是這樣子\n\n13\n00:04:43,743 --> 00:04:53,728\n39歲留任都還留任成功我們很感謝這些資深的護理師扛起了這個責任可是呢我擔心的當然是年輕的子卿沒有進來\n\n14\n00:04:55,100 --> 00:05:17,152\n年輕的族群沒進來可是我們的養成班開很多啊我們現在要問的是說剛剛已經有委員講了到澳洲年薪170萬到美國300萬起跳但都還要扣掉生活費那如果在這裡的待遇和工時能夠改善的話大家都知道說大家如果可以留在自己的家鄉誰願意遠離故鄉呢\n\n15\n00:05:20,854 --> 00:05:42,865\n不是了解而已你們開源人數理論上是增加的取得證照的人數也越來越多可是我們平均職業年齡卻越來越高這是不合理的這種狀況裡面畢業生不來心血留不住資深扛起來然後病房關床急診永設一環扣一環\n\n16\n00:05:45,159 --> 00:05:51,601\n這些畢業生留到外國去難道台灣是要幫變成一個國際護理師的執訓中心嗎台灣護理人才的養成是要幫國際的護理人員變成後備養成中心嗎\n\n17\n00:06:02,332 --> 00:06:27,762\n我們很希望我們培養出來的都能夠留在國內因為國內還是需要這些人才我們想盡辦法把他留在國內所以我們現在是政策規劃是有問題還是政策規劃不利還是執行面有問題所以在這種狀況裡面不要動不動就覺得說你們市長剛剛講說我們人數是增加的人數增加都資深的年輕的優秀的沒有心血進來\n\n18\n00:06:29,062 --> 00:06:38,220\n所以你的KPI應該是護理人員回流多少病床開床率是多少而不是在這裡說你有增加可是結果病床關的越多急診越湧射\n\n19\n00:06:41,366 --> 00:06:51,175\n現在護理人員講啊如果是醫生或醫院跟你們反映問題你們都馬上回應有所回應護理人力跟你們反映問題護理工會跟你們反映問題你們毫無感覺只好護理人員用集體離職來跟你們做無聲的抗議\n\n20\n00:07:02,322 --> 00:07:30,499\n現在是人家反映了你們對於護理人員跟對於醫師跟對醫院他們講話的份量不一樣啊份量不一樣只好用離職來告訴你他抗議這是大問題捏不對嗎要怎麼走要怎麼走你的12項政策政策工具現在好像也是留住資深的而已資深的而已\n\n21\n00:07:31,636 --> 00:07:53,289\n我們很希望因為一進來他工作是不是滿意新手啦新手其實是非常重要的所以我們有這個護理新手的臨床導師好啦我希望半年後你來告訴我你十二項政策讓年輕的護理師願意留下來為台灣的病患服務我們前一步\n\n22\n00:07:55,624 --> 00:08:09,412\n半年後我會再問你喔就不要再講半年前我問你的這個醫院有公安危機的你還沒告訴我還沒回答我喔當然我今天還有更重要的要問你就是因為有這個問題以外還有\n\n23\n00:08:12,074 --> 00:08:39,803\n今年實施的醫院個別總額制的問題在第二季要上路了醫院個別總額制的問題啊你們有一個很有效的打擊醫療人球的策略和方案那你有很有效的羅伯安棒子你知道總額健保總額增加了700多億醫院增加了300多億吧至少醫院拿走了一半以上吧\n\n24\n00:08:41,344 --> 00:08:42,288\n那一人\n\n25\n00:08:43,539 --> 00:09:10,637\n拿多了幾百億的錢出來可是醫院就這樣子急診永設然後現在關病床這已經是夠荒謬夠好笑了我今年要給你三四百億結果關了病床更多結果急診更永設然後你說你有一個醫療人球的這個應對的這個策略這樣子那我現在問你喔就是說啊你有沒有盤點到\n\n26\n00:09:14,396 --> 00:09:16,862\n這個未來醫院個別總額制醫療現場會面臨哪一些衝擊\n\n27\n00:09:23,066 --> 00:09:44,202\n阿你又有什麼因應的策略我可不可以分兩段來報告一下因為我們所有今年的預算都還沒有setdown所以還沒有開始來來能夠去落實各種不管是醫院基層相關包括這個年負病比的獎金現在都還沒有開始來發我想希望能夠\n\n28\n00:09:45,663 --> 00:09:53,188\n預算這個會計都能夠趕快做完你現在是在說什麼說什麼個別醫院總額次啊對你個別醫院總額我們當然知道個別醫院總額是這樣子在台北區也是第二劑才會開始所以你個別醫院總額也是第二劑才要開始啊台北區現在所發生的醫院用色的問題\n\n29\n00:10:07,407 --> 00:10:12,511\n當然應該是還沒有我沒有在問你這個我現在問你是說那個別醫院總額的話我們當然你這樣子實施這個醫院個別總額制實行下去以後醫療現場會發生什麼樣的變化那看病的民眾會受到什麼衝擊我現在是在問這個啊了解\n\n30\n00:10:27,222 --> 00:10:33,608\n我是站在病人和人民的立場在問這個我想這個也不是說突然要去做不是啦會有什麼衝擊你怎麼講不出來沒關係我沒有管你我沒有突然而且我也不見得說認為這樣子是錯的我不認為這樣子就一定是不行的\n\n31\n00:10:46,518 --> 00:11:06,362\n但我現在問你是說有可能面臨到看病的人會受到的衝擊是什麼你來告訴我因為你告訴我了所以你才有想說你的因應策略是什麼那證明你每一個政策新的政策的施行都是有評估有步驟而且到最後的衝擊你們也有因應的策略的我是要看到這個過程啊所以我現在問你\n\n32\n00:11:13,599 --> 00:11:15,882\n這樣子新的制度上路你有沒有盤點過醫療現場會面臨什麼衝擊\n\n33\n00:11:20,310 --> 00:11:41,655\n第一個是什麼我想醫院在財務的自我管理會更加的一個謹慎那如果說他的管理他對病人就會用最有效益的方式來解決你可不可以講具體一點啊不然我說給你聽你補正耶不然我說給你聽啦我再舉個例子他的大姨的日子\n\n34\n00:11:44,496 --> 00:11:53,681\n聽你講這個我認為你不使人間煙火因為很多醫院都跳出來反應了很多醫院的發言人都出來講話了第一個根據媒體的報導台大\n\n35\n00:11:59,864 --> 00:12:27,861\n民眾最擔心的就是醫學中心掛號費會不會調漲然後呢台大醫院目前掛號費100健保部分負擔420然後呢發言人就表示各種醫療支出要價不斷攀升去年點值不到0.9仍然遠遠的趕不上高漲的電費人事費為了因應可能的財務衝擊他們已經商量很多了然後他們不排除最後一個就是調漲掛號費\n\n36\n00:12:29,762 --> 00:12:49,176\n然後新光醫院的副院長大家都知道醫務管理學會的理事長洪子仁也表示不過他們講的更多他們盤點醫院量能他們能做的調控措施包括調高掛費以外減少週六及夜間門診控制掛號人數延後非緊急手術等等\n\n37\n00:12:56,254 --> 00:12:57,537\n現在這事情有嚴重嗎?我現在講這個可能的衝擊在這裡生病的人會受到的衝擊\n\n38\n00:13:06,408 --> 00:13:26,785\n那錢會開過的還算是最小的調高掛號費再來開集也不會開過的週末假日還有夜間門診減少了開集要去掛號又掛不到了控制掛號人數你要去看也掛不到了半夜的週末的集中症的\n\n39\n00:13:28,387 --> 00:13:40,095\n延後非緊急手術那意思是說都要碰瓶子那瓶子不上不下集中症當然排除在那個外面啦但是呢還有一種是減傷\n\n40\n00:13:42,920 --> 00:13:48,205\n輕的報重的這也不可能啊當然這種狀況調整掛號費還掛不到號這民怨四起啊對民眾來講可能衝擊到醫療品質掛號看診困難自費項目變多手術被延後然後消基會的董事吳榮達他擔憂啊\n\n41\n00:14:03,599 --> 00:14:08,801\n這一個新制上路醫療品質會下降醫院如果縮門診量民眾掛號看診更困難影響就醫的可敬性當然我們希望分級醫療所以這個縮門診量是對是錯我們暫姑且不論但是這個蕭紀惠董事會講就檢驗檢查手術時間的遞延也會影響病情的發現導致病情惡化\n\n42\n00:14:31,750 --> 00:14:44,834\n如果醫院若自行限縮醫療服務的申報門診檢查檢驗手術住院減少可能會影響這個事情再來喔醫療人員的收入加劇人力的出走這你們有想過嗎\n\n43\n00:14:48,720 --> 00:15:02,766\n你知不知道不是我們不支持分級醫療有時候到小診所然後醫生檢查不出問題都會叫我們說你為了慎重起見到醫學中心去做檢查有沒有這種狀況\n\n44\n00:15:04,148 --> 00:15:11,275\n有啊很多啊還有一個根據媒體報導56歲的楊女士服用高血壓的藥6年照都在台中榮總心臟內科定期回診拿單然後呢她也不懂什麼是腫瘀然後為了要掛號她覺得掛號費漲她會吞下去但是她曾經因為服用醫院給的藥不要忘了你們還有缺藥的問題喔\n\n45\n00:15:29,591 --> 00:15:42,115\n你們缺藥的問題尤其是一些特殊的藥只有供給給醫院沒有供給給地區醫院也沒有供給給地方診所也沒有供給給地區的藥房結果他說他的經驗是他病情穩定了醫院將他下轉到診所\n\n46\n00:15:47,196 --> 00:16:02,761\n從診所從原廠藥變學名藥還需要在醫學中心回診已經每半年都抽血檢驗看這個一下在診所檢驗又要回到醫學中心就算了但是呢後來檢查好以後他有時候又要到發現變嚴重了又要到中榮去就診\n\n47\n00:16:09,810 --> 00:16:24,728\n這個我們要講的是說分級是對的但是有很多狀況並不是民眾迷信醫學醫院或教學中心而是事情的原本就是這樣直接治療好控制好你叫我去診所就控制不好我就要回來\n\n48\n00:16:26,471 --> 00:16:39,144\n這個教學中心所以這個很複雜的不一定大家都喜歡逛醫院也不一定大家都認為到醫學中心好可是他的經驗就是如此所以他覺得說這個狀況怎麼處理呢你不可以僅憑政策的調整或是你們從上面講說就是這樣子沒問題可以改變了\n\n49\n00:16:47,552 --> 00:16:52,415\n你要去掌握民眾的就醫習慣和決策的行為這是很複雜的你單純調高掛號費也不代表能夠有效的降低民眾因輕症前往醫學中心的就診的狀況這個我也質詢過你調整了部分負擔結果呢結果呢到醫學中心裡面看病的看門診的量增加增加\n\n50\n00:17:17,072 --> 00:17:24,080\n現在只有改變什麼從人民的荷包掏出更多錢這一件事情而已你想要做的分級醫療沒有改變你當初漲部分負擔就說是為了要落實分級醫療結果沒有辦法控制啊\n\n51\n00:17:32,088 --> 00:17:34,289\n無效啊無效的政策啊那現在呢醫改會也擔心啦門診減量以後醫院可能會透過健保轉資費減少賣信簽的處方簽的釋出調漲掛號費來增加收入導致病人看病變貴\n\n52\n00:17:50,558 --> 00:18:07,904\n那為了讓治療項目得到保障甚至可能會將輕症報為重症那為了避免過度申報而斷頭給付他也可能會發展什麼我報太多被斷頭給付那他要怎麼因應如果你是醫院接應者你要怎麼因應部長\n\n53\n00:18:09,822 --> 00:18:25,468\n真的很敬佩委員你覺得他們上有政策下有對策你覺得醫院會怎麼因應啊他是非常複雜的因素但是我必須要跟大家講說今天我們生活在台灣這個國度是非常幸福的\n\n54\n00:18:25,828 --> 00:18:34,812\n我現在要跟你說你的政策有問題沒有啦我投資你政策可能的問題在哪裡沒有啦你講不出來我就告訴你啦醫院你一直去看他沒有辦法負責別人我們一定要改革讓他練保養讓永遠得到好的照顧\n\n55\n00:18:51,940 --> 00:19:20,297\n我不叫你回答,你一直跟我相親,我要跟你說,北醫要面對這麼多人來看診,他怎麼因應,上有政策下有對策道高於尺,魔高於杖啦北醫要透過門前診所啦將輕症帶出醫院治療啦而門前診所已經很多了,很普遍啦這個就是我們在集合的重點之一集合的重點之一有改變嗎?\n\n56\n00:19:21,567 --> 00:19:50,454\n有解決嗎我們各區的管理在這個部分沒有啦將輕症帶出醫院假裝不是醫院去看的門前診所然後再去瓜分西醫的基層診所的總額從醫院的總額再來瓜分診所的總額而重症的病人如果沒有人要收通通給他送到公立醫院讓護理人力更慌公立醫院的\n\n57\n00:19:51,434 --> 00:20:04,025\n所以如果避免醫院選病人你衝擊的配套在哪裡如果讓人家剛提出來的可能的問題你們是有能力因應的嗎你來告訴我\n\n58\n00:20:05,643 --> 00:20:22,818\n透過健保轉資費你要怎麼處理減少慢性遷的事數你要怎麼處理調漲掛號費但是沒有改善醫療分級的問題你怎麼處理門前診所你說你要列為評鑑的項目但是你沒有效你要怎麼處理我們委員所擔心所提出的請你放心\n\n59\n00:20:29,319 --> 00:20:48,911\n我們一定一個一個去把它監測還有呢保障人權最佳的政府限縮門診你知道台大你們台大健康政策管理研究所門診的數量真的不用太重我現在不跟你說了我現在不請你講你之前在這裡說的黃正熙教授有要替我看其實大家都看了沒有啦我現在沒有在提你台港主席我要問問題他這樣子一直台港我怎麼問\n\n60\n00:20:57,856 --> 00:21:10,499\n我是說台大健康政策管理研究所的副教授郭年珍他最近也撰文指出個別醫院總額上路會遇到的四個問題第一個限縮門診手術是否會影響就醫的限縮門診和手術會不會影響到就醫的可進性\n\n61\n00:21:18,041 --> 00:21:35,737\n那第二個就是說啊如何避免醫療醫院選擇輕症病患啊如何避免啊今年醫院的總額比去年增加了370億欸那預期的點值穩定性會提升啊可是關鍵問題在如果避免影響民眾就醫的可進性和醫療品質很低啊但是有可能\n\n62\n00:21:43,781 --> 00:22:03,394\n醫院我們健保多給了370億然後你們漲部分負擔也增加了醫院的收入然後呢如果再增加掛號費收入又要增加可是未來掛號掛不到然後檢查檢查不到然後未來看病的可靜性會受影響\n\n63\n00:22:04,855 --> 00:22:33,422\n你有沒有可能面臨導致高醫療需求的病患不符但是不符合重症的範圍面臨更大的困難或者是變成全民搶掛號大賽大家都要搶掛號都拜託你不要搶掛號或是促使醫院策略性的選擇輕症病患平轉或上轉醫療資源耗用多的病患給其他公立的醫院進一步的加劇醫療資源分配不均\n\n64\n00:22:35,370 --> 00:23:00,423\n然後再來第三點郭年增教授講的醫院內部資源分配和管理衝突這不是醫病的問題也不是醫院跟病人的問題而已光是醫院內部各分科的內部資源分配和管理就會產生衝突所以在某些科別好看的成本低的然後服務量增加\n\n65\n00:23:01,443 --> 00:23:14,166\n然後薪資裡面呢如果這種像成本高的不賺錢的科別然後人數下降這邊看這個吃力不討好的醫生會收入減成本高的成本低的然後好看的人看越多越賺錢的醫生薪水越來越高\n\n66\n00:23:22,228 --> 00:23:50,404\n光是在這種狀況裡面醫師現有的薪酬制度除了兼行政主管或擔任研究醫師以外仍然都是以不拖你服務的量能為基礎鼓勵多做來分配酬勞和所得可是你當總額受到嚴格的控制然後醫院如果沒有有效的調整薪資激勵這個這個激勵的鼓勵的機制的話你如果反向的鼓勵不要充量然後你沒有鼓勵\n\n67\n00:23:51,405 --> 00:23:52,286\n你這個管理食物上還有一種問題是論人記仇的狀況那你減少醫療你要讓這個醫生和部門之間真的啦這問題很嚴重的譬如說\n\n68\n00:24:10,475 --> 00:24:30,796\n本醫來得住院住院的我們都知道門診轉住院的病患病情比較穩定住院的天數容易管理比較有機會接受自費治療可是急重症的急診他轉住院的病患病情是相對嚴重的住院的時間也不確定的\n\n69\n00:24:32,498 --> 00:24:37,764\n也可能比較容易被排擠有沒有可能在醫院的管理上他們在各部門的住院收留上寧可優先選擇收留門診轉上來的\n\n70\n00:24:47,435 --> 00:24:59,205\n而策略性的將急重症的急診部門的要轉病房的讓他留在急診室導致急診有壓力進一步升高因為這部門和部門之間我也要選定他要選勤課他也要選籌檔的\n\n71\n00:25:07,173 --> 00:25:36,029\n所以在這種狀況裡面這一類的急診和非急診專科的衝突在醫院裡面會不會被進一步的放大畢竟多收一個急診的患者即使能有健保的加成或是排除個別的總額之外相較於門診排成的住院病患哪一個比較符合他們那個部門的利益這個是很現實的因為那個部門也有護理人力缺護理師也考量到我寧可照顧\n\n72\n00:25:36,869 --> 00:25:40,212\n門診轉上來誰要照顧那個急症急重症轉上來的所以為了在這種狀況裡面這個問題都是內部管理會衝突的而犧牲的是病人啦在這種狀況裡面還有一種病床控管的方式並不是由科部統一管理有一些醫院的病床的管理是根據個別醫師資歷去分配的\n\n73\n00:26:03,717 --> 00:26:19,807\n而個別醫師的資歷的分配中它導致有空床仍然無法有效收治急診的病患所以在這裡我並不是說我們反對你分級醫療並不是說你反對你個別醫院的總額管制而是\n\n74\n00:26:21,257 --> 00:26:36,305\n你要做的你要監測的更細緻你的配套機制要更完善而是你要預期到可能的衝擊對病人的衝擊是什麼而你的因應之道是什麼請問我剛剛講那些問題你們的配套是什麼\n\n75\n00:26:41,547 --> 00:26:55,238\n病人受到這麼大的衝擊你的配套是什麼所以在醫界在學界人家已經跟你講你的政府要細緻的進行相關的監測和配套機制你講話怎麼這樣你們現在有什麼細緻的監測和配套機制你們監測的項目有哪些監測的頻率會如何設定監測後的檢討設定多久時間\n\n76\n00:27:07,984 --> 00:27:23,915\n包園,你剛剛提的,不管是郭教授,或者是你提的寶貴的見解其實我們都知道我現在問你,你也在這裡,不是問你知不知道,我問你啊你現在監測的配套機制是什麼,你若不能說,叫你書長來說啦我看你是不會說啦,叫你書長來說你,謝謝記者,讓書長我問一下\n\n77\n00:27:34,679 --> 00:27:46,489\n醫療可見性和品質的衝擊跟委員報告這個個別醫院總額除了台北區之外全部都在今年1月1號都實施了台北區當然是最困難的\n\n78\n00:27:48,371 --> 00:27:53,493\n南區高屏區東區都已經早已實施多年所以這個不是一個新的制度因為這些問題在過去實施之前也都有這樣的疑慮但是實施下去之後我們各區的你不要這樣子好不好中南部的醫療現場的問題跟我們北區會一樣嗎\n\n79\n00:28:12,760 --> 00:28:24,732\n一個大台北地區多少人你知道嗎大台北就好了北北基就好了多少人你告訴我700萬人啊但是大台北地區啊700萬在全台灣三分之一耶北北基而已耶\n\n80\n00:28:29,929 --> 00:28:57,723\n你知道2004年就以醫院卓越計畫之名推行過了類似個別總額的制度了啦這個概念在2004年就做過了那因為部分醫院減少開立藥品種類和數量而且限制門診量導致民眾申訴掛不上號醫院減少開藥種類或數量甚至有醫學中心因為頻繁遭投訴而被中區健保業務組終止合約但是因為當時是自願參與的\n\n81\n00:28:59,884 --> 00:29:26,143\n而未參加的醫院這個點子會讓他下降然後影響了整體醫療生態最後這一個計畫被監察院糾正欸那我不認為現在的計畫跟當時是一模一樣但是你們面對這個的態度你們認為台北的模式跟中南部會一樣都不會有問題學者專家叫你們監測什麼你們要監測了嗎\n\n82\n00:29:29,105 --> 00:29:35,870\n有監測嗎都會參考啦他們叫你監測什麼你先回答我你先回答我他們要求的監測合不合理他們要求監測什麼東西你回答得出來嗎\n\n83\n00:29:46,277 --> 00:30:14,966\n我們有很多的指標在檢測他在說你們都知道知道你連聽都不想聽人家建議監測實施前後的實施前後的門診和住院病患的屬性變化監測病人就醫流向是不是出現不合理的平轉或下轉引導醫院建立更合理的薪酬和資源分配機制\n\n84\n00:30:16,363 --> 00:30:24,930\n引導醫院建立更合理的星球和資源分配機制你們的對策是什麼你們的手段蘿蔔和棒子是什麼\n\n85\n00:30:29,793 --> 00:30:49,010\n大家都轉到台大和北龍然後像那個人酬的話不收的話是要轉出那邊處分還是還是台大和北龍要負責我真的要語重心長的跟委員報告啦您的資料我們都會我們都了解也會解決但是我不是要來了解我現在問你說人家拋出來的問題\n\n86\n00:30:51,932 --> 00:31:12,364\n他們絕對都是...我是幫醫院拋出來的問題拿來問你我不是在問醫院院長我擔心的是衛福部部長你要怎麼解決而你講不出來所以我擔心啦有蘿蔔有棍子但是不是一個學者所講的就代表全部\n\n87\n00:31:13,044 --> 00:31:18,666\n我現在最好說一句啦現在我最好說一句啦因為我說很久了啦你為大家不是靠上身就可以解決問題你不是大家叫你為上身就可以解決問題今天在這裡是說人家提出問題了你有什麼看法你有什麼解方你面對病人受到這麼大的衝擊你的配套是什麼而今天\n\n88\n00:31:41,713 --> 00:32:03,559\n而今天整個衛福部包括部長包括署長都對我們提出來的病人受到衝擊回答不出來不願意回答然後轉移焦點答非所問這才是大問題啦我們會解決所有的您擔心的問題大家宣誓性的唯獨一再的宣誓而已謝謝\n\n","tsv":"start\tend\ttext\n4106\t7387\t謝謝主席我們是不是請邱部長委員好部長好今天大家談了很多這個急診詠攝和護理人力的問題但我今天還是要繼續講這個\n25726\t41434\t大家都在談說這個病房護病比的限制護理人力的不足導致醫院這個關病房然後急診的住院帶床病人滯留狀況加劇那上次我也就教於你就是說光是減傷第一級的\n41954\t68095\t他的平均的流治的時間都超過標準時間8小時的還要到雙倍以上那我現在就請你看一個圖到底我們這個護理人力你對於平均媒體報導這個護理人力平均年齡39歲資深護理師留任這個健校你們自己是這樣講留任健校你是怎麼看待這個資訊的\n71670\t88445\t我是請那個市長先回答一下我是叫你看安安就是這樣講你自己發布的新聞你們自己的這個你自己都沒看過嗎就是說啊這個2024因為這個時候我還沒上任所以我要仔細看一下這樣子\n89926\t107137\t不是啊這是前幾天5月去年5月13號的新聞你還沒上任好那你知道這個議題也應該要了解一下吧因為我當然是希望護理師生能夠留任不是啦現在從一路早上大家問你都覺得說\n109178\t126031\t離職的雖然很多但你們12項政策要求穩定而且已經有見效增加的人力其實都是增加的雖然有離職的但你們剛才司長一直在講說人力普遍上還是增加的從你們的職登統計都看得出來那你們現在看出來數據我告訴你2021年護理師職業的平均年齡是36.95歲2024年是39.25歲\n137879\t159435\t那我就這樣子問你就好了 就這件事情啦職業的平均年齡越來越增加 你怎麼看待這一件事情平均職業年齡提高啊你怎麼看啊這可能要從兩個角度嘛\n162048\t180898\t因為當初去年你們認為這個是肯定把資深的留下來從這個角度來看也許是好事情那是不是說年輕的留不住也是一件事情這個可能要來看評但我們也很好奇為什麼年輕的因為我們開設多元的人才人力的培養\n181718\t202436\t包括學社後的護理系有持續的開設而且包括護理師的考試從一年兩次變成一年三次但我們的平均職業年齡卻節節攀升那你講的你也講了就是說啊這個留不住年輕的專業的護理人力那你知道部長你知道2012年台灣護理人員平均職業年齡是幾歲嗎2012年\n211962\t220613\t2012年啦 你猜猜看 你用猜的啦 你們沒數據啦 你用猜的 你猜猜看好 那多少歲 被你偷看到了2012年29.6歲 2024年39.25歲\n230520\t234883\t當時2012年2012年離現在並沒有很久你們專案報告是說平均年齡29歲而且21到30歲族群最多佔了43.6%43.6%都是30歲以下的護理人力而現在30歲以下護理人力可能是\n254895\t271866\t低的不像樣那你對這個數字其實你都沒有掌握我剛剛問你 你也搞不清楚到底我們要肯定平均年齡39歲是留任成功還是說我們要擔心如果2012年平均年齡29歲2024年平均39歲如果照這個邏輯到2036年平均職業年齡會不會變成49歲有沒有可能是這樣子\n283743\t293728\t39歲留任都還留任成功我們很感謝這些資深的護理師扛起了這個責任可是呢我擔心的當然是年輕的子卿沒有進來\n295100\t317152\t年輕的族群沒進來可是我們的養成班開很多啊我們現在要問的是說剛剛已經有委員講了到澳洲年薪170萬到美國300萬起跳但都還要扣掉生活費那如果在這裡的待遇和工時能夠改善的話大家都知道說大家如果可以留在自己的家鄉誰願意遠離故鄉呢\n320854\t342865\t不是了解而已你們開源人數理論上是增加的取得證照的人數也越來越多可是我們平均職業年齡卻越來越高這是不合理的這種狀況裡面畢業生不來心血留不住資深扛起來然後病房關床急診永設一環扣一環\n345159\t351601\t這些畢業生留到外國去難道台灣是要幫變成一個國際護理師的執訓中心嗎台灣護理人才的養成是要幫國際的護理人員變成後備養成中心嗎\n362332\t387762\t我們很希望我們培養出來的都能夠留在國內因為國內還是需要這些人才我們想盡辦法把他留在國內所以我們現在是政策規劃是有問題還是政策規劃不利還是執行面有問題所以在這種狀況裡面不要動不動就覺得說你們市長剛剛講說我們人數是增加的人數增加都資深的年輕的優秀的沒有心血進來\n389062\t398220\t所以你的KPI應該是護理人員回流多少病床開床率是多少而不是在這裡說你有增加可是結果病床關的越多急診越湧射\n401366\t411175\t現在護理人員講啊 如果是醫生或醫院跟你們反映問題 你們都馬上回應有所回應 護理人力跟你們反映問題 護理工會跟你們反映問題你們毫無感覺 只好護理人員用集體離職來跟你們做無聲的抗議\n422322\t450499\t現在是人家反映了你們對於護理人員跟對於醫師跟對醫院他們講話的份量不一樣啊份量不一樣只好用離職來告訴你他抗議這是大問題捏不對嗎要怎麼走要怎麼走你的12項政策政策工具現在好像也是留住資深的而已資深的而已\n451636\t473289\t我們很希望因為一進來他工作是不是滿意新手啦新手其實是非常重要的所以我們有這個護理新手的臨床導師好啦我希望半年後你來告訴我你十二項政策讓年輕的護理師願意留下來為台灣的病患服務我們前一步\n475624\t489412\t半年後我會再問你喔就不要再講半年前我問你的這個醫院有公安危機的你還沒告訴我還沒回答我喔當然我今天還有更重要的要問你就是因為有這個問題以外還有\n492074\t519803\t今年實施的醫院個別總額制的問題在第二季要上路了醫院個別總額制的問題啊你們有一個很有效的打擊醫療人球的策略和方案那你有很有效的羅伯安棒子你知道總額健保總額增加了700多億醫院增加了300多億吧至少醫院拿走了一半以上吧\n521344\t522288\t那一人\n523539\t550637\t拿多了幾百億的錢出來可是醫院就這樣子急診永設然後現在關病床這已經是夠荒謬 夠好笑了我今年要給你三四百億結果關了病床更多結果急診更永設然後你說你有一個醫療人球的這個應對的這個策略這樣子那我現在問你喔 就是說啊你有沒有盤點到\n554396\t556862\t這個未來醫院個別總額制醫療現場會面臨哪一些衝擊\n563066\t584202\t阿你又有什麼因應的策略我可不可以分兩段來報告一下因為我們所有今年的預算都還沒有set down所以還沒有開始來來能夠去落實各種不管是醫院基層相關包括這個年負病比的獎金現在都還沒有開始來發我想希望能夠\n585663\t593188\t預算這個會計都能夠趕快做完你現在是在說什麼 說什麼個別醫院總額次啊對你個別醫院總額我們當然知道個別醫院總額是這樣子在台北區也是第二劑才會開始所以你個別醫院總額也是第二劑才要開始啊台北區現在所發生的醫院用色的問題\n607407\t612511\t當然應該是還沒有我沒有在問你這個我現在問你是說那個別醫院總額的話我們當然你這樣子實施這個醫院個別總額制實行下去以後醫療現場會發生什麼樣的變化那看病的民眾會受到什麼衝擊我現在是在問這個啊了解\n627222\t633608\t我是站在病人和人民的立場在問這個我想這個也不是說突然要去做不是啦會有什麼衝擊你怎麼講不出來沒關係我沒有管你我沒有突然而且我也不見得說認為這樣子是錯的我不認為這樣子就一定是不行的\n646518\t666362\t但我現在問你是說有可能面臨到看病的人會受到的衝擊是什麼你來告訴我因為你告訴我了所以你才有想說你的因應策略是什麼那證明你每一個政策新的政策的施行都是有評估有步驟而且到最後的衝擊你們也有因應的策略的我是要看到這個過程啊所以我現在問你\n673599\t675882\t這樣子新的制度上路你有沒有盤點過醫療現場會面臨什麼衝擊\n680310\t701655\t第一個是什麼我想醫院在財務的自我管理會更加的一個謹慎那如果說他的管理他對病人就會用最有效益的方式來解決你可不可以講具體一點啊不然我說給你聽你補正耶不然我說給你聽啦我再舉個例子他的大姨的日子\n704496\t713681\t聽你講這個我認為你不使人間煙火因為很多醫院都跳出來反應了很多醫院的發言人都出來講話了第一個根據媒體的報導台大\n719864\t747861\t民眾最擔心的就是醫學中心掛號費會不會調漲然後呢台大醫院目前掛號費100健保部分負擔420然後呢發言人就表示各種醫療支出要價不斷攀升去年點值不到0.9仍然遠遠的趕不上高漲的電費人事費為了因應可能的財務衝擊他們已經商量很多了然後他們不排除最後一個就是調漲掛號費\n749762\t769176\t然後新光醫院的副院長大家都知道醫務管理學會的理事長洪子仁也表示不過他們講的更多他們盤點醫院量能他們能做的調控措施包括調高掛費以外減少週六及夜間門診控制掛號人數延後非緊急手術等等\n776254\t777537\t現在這事情有嚴重嗎?我現在講這個可能的衝擊在這裡生病的人會受到的衝擊\n786408\t806785\t那錢會開過的還算是最小的 調高掛號費再來開集也不會開過的週末假日還有夜間門診減少了開集要去掛號又掛不到了控制掛號人數你要去看也掛不到了半夜的週末的集中症的\n808387\t820095\t延後非緊急手術那意思是說都要碰瓶子那瓶子不上不下集中症當然排除在那個外面啦但是呢還有一種是減傷\n822920\t828205\t輕的報重的 這也不可能啊當然這種狀況 調整掛號費還掛不到號 這民怨四起啊對民眾來講 可能衝擊到醫療品質 掛號看診困難自費項目變多 手術被延後然後消基會的董事吳榮達 他擔憂啊\n843599\t848801\t這一個新制上路醫療品質會下降醫院如果縮門診量民眾掛號看診更困難影響就醫的可敬性當然我們希望分級醫療所以這個縮門診量是對是錯我們暫姑且不論但是這個蕭紀惠董事會講就檢驗檢查手術時間的遞延也會影響病情的發現導致病情惡化\n871750\t884834\t如果醫院若自行限縮醫療服務的申報門診檢查檢驗手術住院減少可能會影響這個事情再來喔醫療人員的收入加劇人力的出走這你們有想過嗎\n888720\t902766\t你知不知道不是我們不支持分級醫療有時候到小診所然後醫生檢查不出問題都會叫我們說你為了慎重起見到醫學中心去做檢查有沒有這種狀況\n904148\t911275\t有啊很多啊還有一個根據媒體報導56歲的楊女士服用高血壓的藥6年照都在台中榮總心臟內科定期回診拿單然後呢她也不懂什麼是腫瘀然後為了要掛號她覺得掛號費漲她會吞下去但是她曾經因為服用醫院給的藥不要忘了你們還有缺藥的問題喔\n929591\t942115\t你們缺藥的問題尤其是一些特殊的藥只有供給給醫院沒有供給給地區醫院也沒有供給給地方診所也沒有供給給地區的藥房結果他說他的經驗是他病情穩定了醫院將他下轉到診所\n947196\t962761\t從診所 從原廠藥變學名藥還需要在醫學中心回診 已經每半年都抽血檢驗看這個一下在診所 檢驗又要回到醫學中心就算了但是呢 後來 檢查好以後 他有時候又要到發現變嚴重了 又要到中榮去就診\n969810\t984728\t這個我們要講的是說分級是對的但是有很多狀況並不是民眾迷信醫學醫院或教學中心而是事情的原本就是這樣直接治療好控制好你叫我去診所就控制不好我就要回來\n986471\t999144\t這個教學中心所以這個很複雜的不一定大家都喜歡逛醫院也不一定大家都認為到醫學中心好可是他的經驗就是如此所以他覺得說這個狀況怎麼處理呢你不可以僅憑政策的調整或是你們從上面講說就是這樣子沒問題可以改變了\n1007552\t1012415\t你要去掌握民眾的就醫習慣和決策的行為這是很複雜的你單純調高掛號費也不代表能夠有效的降低民眾因輕症前往醫學中心的就診的狀況這個我也質詢過你調整了部分負擔結果呢結果呢 到醫學中心裡面看病的 看門診的量增加 增加\n1037072\t1044080\t現在只有改變什麼從人民的荷包掏出更多錢這一件事情而已你想要做的分級醫療沒有改變你當初漲部分負擔就說是為了要落實分級醫療結果沒有辦法控制啊\n1052088\t1054289\t無效啊 無效的政策啊那現在呢醫改會也擔心啦門診減量以後醫院可能會透過健保轉資費減少賣信簽的處方簽的釋出調漲掛號費來增加收入導致病人看病變貴\n1070558\t1087904\t那為了讓治療項目得到保障甚至可能會將輕症報為重症那為了避免過度申報而斷頭給付他也可能會發展什麼我報太多被斷頭給付那他要怎麼因應如果你是醫院接應者你要怎麼因應部長\n1089822\t1105468\t真的很敬佩委員你覺得他們上有政策下有對策你覺得醫院會怎麼因應啊他是非常複雜的因素但是我必須要跟大家講說今天我們生活在台灣這個國度是非常幸福的\n1105828\t1114812\t我現在要跟你說你的政策有問題沒有啦我投資你政策可能的問題在哪裡沒有啦你講不出來我就告訴你啦醫院你一直去看他沒有辦法負責別人我們一定要改革讓他練保養讓永遠得到好的照顧\n1131940\t1160297\t我不叫你回答,你一直跟我相親,我要跟你說,北醫要面對這麼多人來看診,他怎麼因應,上有政策下有對策道高於尺,魔高於杖啦北醫要透過門前診所啦將輕症帶出醫院治療啦而門前診所已經很多了,很普遍啦這個就是我們在集合的重點之一集合的重點之一有改變嗎?\n1161567\t1190454\t有解決嗎我們各區的管理在這個部分沒有啦將輕症帶出醫院假裝不是醫院去看的門前診所然後再去瓜分西醫的基層診所的總額從醫院的總額再來瓜分診所的總額而重症的病人如果沒有人要收通通給他送到公立醫院讓護理人力更慌公立醫院的\n1191434\t1204025\t所以如果避免醫院選病人你衝擊的配套在哪裡如果讓人家剛提出來的可能的問題你們是有能力因應的嗎你來告訴我\n1205643\t1222818\t透過健保轉資費你要怎麼處理減少慢性遷的事數你要怎麼處理調漲掛號費但是沒有改善醫療分級的問題你怎麼處理門前診所你說你要列為評鑑的項目但是你沒有效你要怎麼處理我們委員所擔心所提出的請你放心\n1229319\t1248911\t我們一定一個一個去把它監測還有呢保障人權最佳的政府限縮門診你知道台大你們台大健康政策管理研究所門診的數量真的不用太重我現在不跟你說了我現在不請你講你之前在這裡說的黃正熙教授有要替我看其實大家都看了沒有啦我現在沒有在提你台港主席我要問問題他這樣子一直台港我怎麼問\n1257856\t1270499\t我是說台大健康政策管理研究所的副教授郭年珍他最近也撰文指出個別醫院總額上路會遇到的四個問題第一個限縮門診手術是否會影響就醫的限縮門診和手術會不會影響到就醫的可進性\n1278041\t1295737\t那第二個就是說啊如何避免醫療醫院選擇輕症病患啊如何避免啊今年醫院的總額比去年增加了370億欸那預期的點值穩定性會提升啊可是關鍵問題在如果避免影響民眾就醫的可進性和醫療品質很低啊但是有可能\n1303781\t1323394\t醫院我們健保多給了370億然後你們漲部分負擔也增加了醫院的收入然後呢如果再增加掛號費收入又要增加可是未來掛號掛不到然後檢查檢查不到然後未來看病的可靜性會受影響\n1324855\t1353422\t你有沒有可能面臨導致高醫療需求的病患不符但是不符合重症的範圍面臨更大的困難或者是變成全民搶掛號大賽大家都要搶掛號都拜託你不要搶掛號或是促使醫院策略性的選擇輕症病患平轉或上轉醫療資源耗用多的病患給其他公立的醫院進一步的加劇醫療資源分配不均\n1355370\t1380423\t然後再來第三點 郭年增教授講的醫院內部資源分配和管理衝突這不是醫病的問題 也不是醫院跟病人的問題而已光是醫院內部各分科的內部資源分配和管理就會產生衝突所以在某些科別好看的 成本低的 然後服務量增加\n1381443\t1394166\t然後薪資裡面呢 如果這種像成本高的不賺錢的科別 然後人數下降這邊看這個吃力不討好的 醫生會收入減成本高的 成本低的 然後好看的 人看越多越賺錢的 醫生薪水越來越高\n1402228\t1430404\t光是在這種狀況裡面醫師現有的薪酬制度除了兼行政主管或擔任研究醫師以外仍然都是以不拖你服務的量能為基礎鼓勵多做來分配酬勞和所得可是你當總額受到嚴格的控制然後醫院如果沒有有效的調整薪資激勵這個這個激勵的鼓勵的機制的話你如果反向的鼓勵不要充量然後你沒有鼓勵\n1431405\t1432286\t你這個管理食物上還有一種問題是論人記仇的狀況那你減少醫療你要讓這個醫生和部門之間真的啦這問題很嚴重的譬如說\n1450475\t1470796\t本醫來得住院 住院的我們都知道門診轉住院的病患病情比較穩定住院的天數容易管理比較有機會接受自費治療可是急重症的急診他轉住院的病患病情是相對嚴重的住院的時間也不確定的\n1472498\t1477764\t也可能比較容易被排擠有沒有可能在醫院的管理上他們在各部門的住院收留上寧可優先選擇收留門診轉上來的\n1487435\t1499205\t而策略性的將急重症的急診部門的要轉病房的讓他留在急診室導致急診有壓力進一步升高因為這部門和部門之間 我也要選定他要選勤課 他也要選籌檔的\n1507173\t1536029\t所以在這種狀況裡面這一類的急診和非急診專科的衝突在醫院裡面會不會被進一步的放大畢竟多收一個急診的患者即使能有健保的加成或是排除個別的總額之外相較於門診排成的住院病患哪一個比較符合他們那個部門的利益這個是很現實的因為那個部門也有護理人力缺護理師也考量到我寧可照顧\n1536869\t1540212\t門診轉上來誰要照顧那個急症急重症轉上來的所以為了在這種狀況裡面這個問題都是內部管理會衝突的而犧牲的是病人啦在這種狀況裡面還有一種病床控管的方式並不是由科部統一管理有一些醫院的病床的管理是根據個別醫師資歷去分配的\n1563717\t1579807\t而個別醫師的資歷的分配中它導致有空床仍然無法有效收治急診的病患所以在這裡我並不是說我們反對你分級醫療並不是說你反對你個別醫院的總額管制而是\n1581257\t1596305\t你要做的你要監測的更細緻你的配套機制要更完善而是你要預期到可能的衝擊對病人的衝擊是什麼而你的因應之道是什麼請問我剛剛講那些問題你們的配套是什麼\n1601547\t1615238\t病人受到這麼大的衝擊 你的配套是什麼所以在醫界 在學界人家已經跟你講你的政府要細緻的進行相關的監測和配套機制你講話怎麼這樣你們現在有什麼細緻的監測和配套機制你們監測的項目有哪些監測的頻率會如何設定監測後的檢討設定多久時間\n1627984\t1643915\t包園,你剛剛提的,不管是郭教授,或者是你提的寶貴的見解其實我們都知道我現在問你,你也在這裡,不是問你知不知道,我問你啊你現在監測的配套機制是什麼,你若不能說,叫你書長來說啦我看你是不會說啦,叫你書長來說你,謝謝記者,讓書長我問一下\n1654679\t1666489\t醫療可見性和品質的衝擊跟委員報告這個個別醫院總額除了台北區之外全部都在今年1月1號都實施了台北區當然是最困難的\n1668371\t1673493\t南區高屏區東區都已經早已實施多年所以這個不是一個新的制度因為這些問題在過去實施之前也都有這樣的疑慮但是實施下去之後我們各區的你不要這樣子好不好中南部的醫療現場的問題跟我們北區會一樣嗎\n1692760\t1704732\t一個大台北地區多少人你知道嗎大台北就好了北北基就好了多少人你告訴我700萬人啊但是大台北地區啊700萬在全台灣三分之一耶北北基而已耶\n1709929\t1737723\t你知道2004年就以醫院卓越計畫之名推行過了類似個別總額的制度了啦這個概念在2004年就做過了那因為部分醫院減少開立藥品種類和數量而且限制門診量導致民眾申訴掛不上號醫院減少開藥種類或數量甚至有醫學中心因為頻繁遭投訴而被中區健保業務組終止合約但是因為當時是自願參與的\n1739884\t1766143\t而未參加的醫院這個點子會讓他下降然後影響了整體醫療生態最後這一個計畫被監察院糾正欸那我不認為現在的計畫跟當時是一模一樣但是你們面對這個的態度你們認為台北的模式跟中南部會一樣都不會有問題學者專家叫你們監測什麼你們要監測了嗎\n1769105\t1775870\t有監測嗎 都會參考啦他們叫你監測什麼 你先回答我你先回答我 他們要求的監測合不合理他們要求監測什麼東西 你回答得出來嗎\n1786277\t1814966\t我們有很多的指標在檢測他在說你們都知道知道 你連聽都不想聽人家建議 監測實施前後的實施前後的門診和住院病患的屬性變化監測病人就醫流向是不是出現不合理的平轉或下轉引導醫院建立更合理的薪酬和資源分配機制\n1816363\t1824930\t引導醫院建立更合理的星球和資源分配機制你們的對策是什麼你們的手段 蘿蔔和棒子是什麼\n1829793\t1849010\t大家都轉到台大和北龍然後像那個人酬的話不收的話是要轉出那邊處分還是還是台大和北龍要負責我真的要語重心長的跟委員報告啦您的資料我們都會我們都了解也會解決但是我不是要來了解我現在問你說人家拋出來的問題\n1851932\t1872364\t他們絕對都是...我是幫醫院拋出來的問題拿來問你我不是在問醫院院長我擔心的是衛福部部長你要怎麼解決而你講不出來所以我擔心啦有蘿蔔有棍子但是不是一個學者所講的就代表全部\n1873044\t1878666\t我現在最好說一句啦現在我最好說一句啦 因為我說很久了啦你為大家不是靠上身就可以解決問題你不是大家叫你為上身就可以解決問題今天在這裡是說 人家提出問題了你有什麼看法 你有什麼解方你面對病人受到這麼大的衝擊 你的配套是什麼而今天\n1901713\t1923559\t而今天整個衛福部包括部長包括署長都對我們提出來的病人受到衝擊回答不出來不願意回答然後轉移焦點答非所問這才是大問題啦我們會解決所有的您擔心的問題大家宣誓性的唯獨一再的宣誓而已謝謝\n","txt":"謝謝主席我們是不是請邱部長委員好部長好今天大家談了很多這個急診詠攝和護理人力的問題但我今天還是要繼續講這個\n大家都在談說這個病房護病比的限制護理人力的不足導致醫院這個關病房然後急診的住院帶床病人滯留狀況加劇那上次我也就教於你就是說光是減傷第一級的\n他的平均的流治的時間都超過標準時間8小時的還要到雙倍以上那我現在就請你看一個圖到底我們這個護理人力你對於平均媒體報導這個護理人力平均年齡39歲資深護理師留任這個健校你們自己是這樣講留任健校你是怎麼看待這個資訊的\n我是請那個市長先回答一下我是叫你看安安就是這樣講你自己發布的新聞你們自己的這個你自己都沒看過嗎就是說啊這個2024因為這個時候我還沒上任所以我要仔細看一下這樣子\n不是啊這是前幾天5月去年5月13號的新聞你還沒上任好那你知道這個議題也應該要了解一下吧因為我當然是希望護理師生能夠留任不是啦現在從一路早上大家問你都覺得說\n離職的雖然很多但你們12項政策要求穩定而且已經有見效增加的人力其實都是增加的雖然有離職的但你們剛才司長一直在講說人力普遍上還是增加的從你們的職登統計都看得出來那你們現在看出來數據我告訴你2021年護理師職業的平均年齡是36.95歲2024年是39.25歲\n那我就這樣子問你就好了 就這件事情啦職業的平均年齡越來越增加 你怎麼看待這一件事情平均職業年齡提高啊你怎麼看啊這可能要從兩個角度嘛\n因為當初去年你們認為這個是肯定把資深的留下來從這個角度來看也許是好事情那是不是說年輕的留不住也是一件事情這個可能要來看評但我們也很好奇為什麼年輕的因為我們開設多元的人才人力的培養\n包括學社後的護理系有持續的開設而且包括護理師的考試從一年兩次變成一年三次但我們的平均職業年齡卻節節攀升那你講的你也講了就是說啊這個留不住年輕的專業的護理人力那你知道部長你知道2012年台灣護理人員平均職業年齡是幾歲嗎2012年\n2012年啦 你猜猜看 你用猜的啦 你們沒數據啦 你用猜的 你猜猜看好 那多少歲 被你偷看到了2012年29.6歲 2024年39.25歲\n當時2012年2012年離現在並沒有很久你們專案報告是說平均年齡29歲而且21到30歲族群最多佔了43.6%43.6%都是30歲以下的護理人力而現在30歲以下護理人力可能是\n低的不像樣那你對這個數字其實你都沒有掌握我剛剛問你 你也搞不清楚到底我們要肯定平均年齡39歲是留任成功還是說我們要擔心如果2012年平均年齡29歲2024年平均39歲如果照這個邏輯到2036年平均職業年齡會不會變成49歲有沒有可能是這樣子\n39歲留任都還留任成功我們很感謝這些資深的護理師扛起了這個責任可是呢我擔心的當然是年輕的子卿沒有進來\n年輕的族群沒進來可是我們的養成班開很多啊我們現在要問的是說剛剛已經有委員講了到澳洲年薪170萬到美國300萬起跳但都還要扣掉生活費那如果在這裡的待遇和工時能夠改善的話大家都知道說大家如果可以留在自己的家鄉誰願意遠離故鄉呢\n不是了解而已你們開源人數理論上是增加的取得證照的人數也越來越多可是我們平均職業年齡卻越來越高這是不合理的這種狀況裡面畢業生不來心血留不住資深扛起來然後病房關床急診永設一環扣一環\n這些畢業生留到外國去難道台灣是要幫變成一個國際護理師的執訓中心嗎台灣護理人才的養成是要幫國際的護理人員變成後備養成中心嗎\n我們很希望我們培養出來的都能夠留在國內因為國內還是需要這些人才我們想盡辦法把他留在國內所以我們現在是政策規劃是有問題還是政策規劃不利還是執行面有問題所以在這種狀況裡面不要動不動就覺得說你們市長剛剛講說我們人數是增加的人數增加都資深的年輕的優秀的沒有心血進來\n所以你的KPI應該是護理人員回流多少病床開床率是多少而不是在這裡說你有增加可是結果病床關的越多急診越湧射\n現在護理人員講啊 如果是醫生或醫院跟你們反映問題 你們都馬上回應有所回應 護理人力跟你們反映問題 護理工會跟你們反映問題你們毫無感覺 只好護理人員用集體離職來跟你們做無聲的抗議\n現在是人家反映了你們對於護理人員跟對於醫師跟對醫院他們講話的份量不一樣啊份量不一樣只好用離職來告訴你他抗議這是大問題捏不對嗎要怎麼走要怎麼走你的12項政策政策工具現在好像也是留住資深的而已資深的而已\n我們很希望因為一進來他工作是不是滿意新手啦新手其實是非常重要的所以我們有這個護理新手的臨床導師好啦我希望半年後你來告訴我你十二項政策讓年輕的護理師願意留下來為台灣的病患服務我們前一步\n半年後我會再問你喔就不要再講半年前我問你的這個醫院有公安危機的你還沒告訴我還沒回答我喔當然我今天還有更重要的要問你就是因為有這個問題以外還有\n今年實施的醫院個別總額制的問題在第二季要上路了醫院個別總額制的問題啊你們有一個很有效的打擊醫療人球的策略和方案那你有很有效的羅伯安棒子你知道總額健保總額增加了700多億醫院增加了300多億吧至少醫院拿走了一半以上吧\n那一人\n拿多了幾百億的錢出來可是醫院就這樣子急診永設然後現在關病床這已經是夠荒謬 夠好笑了我今年要給你三四百億結果關了病床更多結果急診更永設然後你說你有一個醫療人球的這個應對的這個策略這樣子那我現在問你喔 就是說啊你有沒有盤點到\n這個未來醫院個別總額制醫療現場會面臨哪一些衝擊\n阿你又有什麼因應的策略我可不可以分兩段來報告一下因為我們所有今年的預算都還沒有set down所以還沒有開始來來能夠去落實各種不管是醫院基層相關包括這個年負病比的獎金現在都還沒有開始來發我想希望能夠\n預算這個會計都能夠趕快做完你現在是在說什麼 說什麼個別醫院總額次啊對你個別醫院總額我們當然知道個別醫院總額是這樣子在台北區也是第二劑才會開始所以你個別醫院總額也是第二劑才要開始啊台北區現在所發生的醫院用色的問題\n當然應該是還沒有我沒有在問你這個我現在問你是說那個別醫院總額的話我們當然你這樣子實施這個醫院個別總額制實行下去以後醫療現場會發生什麼樣的變化那看病的民眾會受到什麼衝擊我現在是在問這個啊了解\n我是站在病人和人民的立場在問這個我想這個也不是說突然要去做不是啦會有什麼衝擊你怎麼講不出來沒關係我沒有管你我沒有突然而且我也不見得說認為這樣子是錯的我不認為這樣子就一定是不行的\n但我現在問你是說有可能面臨到看病的人會受到的衝擊是什麼你來告訴我因為你告訴我了所以你才有想說你的因應策略是什麼那證明你每一個政策新的政策的施行都是有評估有步驟而且到最後的衝擊你們也有因應的策略的我是要看到這個過程啊所以我現在問你\n這樣子新的制度上路你有沒有盤點過醫療現場會面臨什麼衝擊\n第一個是什麼我想醫院在財務的自我管理會更加的一個謹慎那如果說他的管理他對病人就會用最有效益的方式來解決你可不可以講具體一點啊不然我說給你聽你補正耶不然我說給你聽啦我再舉個例子他的大姨的日子\n聽你講這個我認為你不使人間煙火因為很多醫院都跳出來反應了很多醫院的發言人都出來講話了第一個根據媒體的報導台大\n民眾最擔心的就是醫學中心掛號費會不會調漲然後呢台大醫院目前掛號費100健保部分負擔420然後呢發言人就表示各種醫療支出要價不斷攀升去年點值不到0.9仍然遠遠的趕不上高漲的電費人事費為了因應可能的財務衝擊他們已經商量很多了然後他們不排除最後一個就是調漲掛號費\n然後新光醫院的副院長大家都知道醫務管理學會的理事長洪子仁也表示不過他們講的更多他們盤點醫院量能他們能做的調控措施包括調高掛費以外減少週六及夜間門診控制掛號人數延後非緊急手術等等\n現在這事情有嚴重嗎?我現在講這個可能的衝擊在這裡生病的人會受到的衝擊\n那錢會開過的還算是最小的 調高掛號費再來開集也不會開過的週末假日還有夜間門診減少了開集要去掛號又掛不到了控制掛號人數你要去看也掛不到了半夜的週末的集中症的\n延後非緊急手術那意思是說都要碰瓶子那瓶子不上不下集中症當然排除在那個外面啦但是呢還有一種是減傷\n輕的報重的 這也不可能啊當然這種狀況 調整掛號費還掛不到號 這民怨四起啊對民眾來講 可能衝擊到醫療品質 掛號看診困難自費項目變多 手術被延後然後消基會的董事吳榮達 他擔憂啊\n這一個新制上路醫療品質會下降醫院如果縮門診量民眾掛號看診更困難影響就醫的可敬性當然我們希望分級醫療所以這個縮門診量是對是錯我們暫姑且不論但是這個蕭紀惠董事會講就檢驗檢查手術時間的遞延也會影響病情的發現導致病情惡化\n如果醫院若自行限縮醫療服務的申報門診檢查檢驗手術住院減少可能會影響這個事情再來喔醫療人員的收入加劇人力的出走這你們有想過嗎\n你知不知道不是我們不支持分級醫療有時候到小診所然後醫生檢查不出問題都會叫我們說你為了慎重起見到醫學中心去做檢查有沒有這種狀況\n有啊很多啊還有一個根據媒體報導56歲的楊女士服用高血壓的藥6年照都在台中榮總心臟內科定期回診拿單然後呢她也不懂什麼是腫瘀然後為了要掛號她覺得掛號費漲她會吞下去但是她曾經因為服用醫院給的藥不要忘了你們還有缺藥的問題喔\n你們缺藥的問題尤其是一些特殊的藥只有供給給醫院沒有供給給地區醫院也沒有供給給地方診所也沒有供給給地區的藥房結果他說他的經驗是他病情穩定了醫院將他下轉到診所\n從診所 從原廠藥變學名藥還需要在醫學中心回診 已經每半年都抽血檢驗看這個一下在診所 檢驗又要回到醫學中心就算了但是呢 後來 檢查好以後 他有時候又要到發現變嚴重了 又要到中榮去就診\n這個我們要講的是說分級是對的但是有很多狀況並不是民眾迷信醫學醫院或教學中心而是事情的原本就是這樣直接治療好控制好你叫我去診所就控制不好我就要回來\n這個教學中心所以這個很複雜的不一定大家都喜歡逛醫院也不一定大家都認為到醫學中心好可是他的經驗就是如此所以他覺得說這個狀況怎麼處理呢你不可以僅憑政策的調整或是你們從上面講說就是這樣子沒問題可以改變了\n你要去掌握民眾的就醫習慣和決策的行為這是很複雜的你單純調高掛號費也不代表能夠有效的降低民眾因輕症前往醫學中心的就診的狀況這個我也質詢過你調整了部分負擔結果呢結果呢 到醫學中心裡面看病的 看門診的量增加 增加\n現在只有改變什麼從人民的荷包掏出更多錢這一件事情而已你想要做的分級醫療沒有改變你當初漲部分負擔就說是為了要落實分級醫療結果沒有辦法控制啊\n無效啊 無效的政策啊那現在呢醫改會也擔心啦門診減量以後醫院可能會透過健保轉資費減少賣信簽的處方簽的釋出調漲掛號費來增加收入導致病人看病變貴\n那為了讓治療項目得到保障甚至可能會將輕症報為重症那為了避免過度申報而斷頭給付他也可能會發展什麼我報太多被斷頭給付那他要怎麼因應如果你是醫院接應者你要怎麼因應部長\n真的很敬佩委員你覺得他們上有政策下有對策你覺得醫院會怎麼因應啊他是非常複雜的因素但是我必須要跟大家講說今天我們生活在台灣這個國度是非常幸福的\n我現在要跟你說你的政策有問題沒有啦我投資你政策可能的問題在哪裡沒有啦你講不出來我就告訴你啦醫院你一直去看他沒有辦法負責別人我們一定要改革讓他練保養讓永遠得到好的照顧\n我不叫你回答,你一直跟我相親,我要跟你說,北醫要面對這麼多人來看診,他怎麼因應,上有政策下有對策道高於尺,魔高於杖啦北醫要透過門前診所啦將輕症帶出醫院治療啦而門前診所已經很多了,很普遍啦這個就是我們在集合的重點之一集合的重點之一有改變嗎?\n有解決嗎我們各區的管理在這個部分沒有啦將輕症帶出醫院假裝不是醫院去看的門前診所然後再去瓜分西醫的基層診所的總額從醫院的總額再來瓜分診所的總額而重症的病人如果沒有人要收通通給他送到公立醫院讓護理人力更慌公立醫院的\n所以如果避免醫院選病人你衝擊的配套在哪裡如果讓人家剛提出來的可能的問題你們是有能力因應的嗎你來告訴我\n透過健保轉資費你要怎麼處理減少慢性遷的事數你要怎麼處理調漲掛號費但是沒有改善醫療分級的問題你怎麼處理門前診所你說你要列為評鑑的項目但是你沒有效你要怎麼處理我們委員所擔心所提出的請你放心\n我們一定一個一個去把它監測還有呢保障人權最佳的政府限縮門診你知道台大你們台大健康政策管理研究所門診的數量真的不用太重我現在不跟你說了我現在不請你講你之前在這裡說的黃正熙教授有要替我看其實大家都看了沒有啦我現在沒有在提你台港主席我要問問題他這樣子一直台港我怎麼問\n我是說台大健康政策管理研究所的副教授郭年珍他最近也撰文指出個別醫院總額上路會遇到的四個問題第一個限縮門診手術是否會影響就醫的限縮門診和手術會不會影響到就醫的可進性\n那第二個就是說啊如何避免醫療醫院選擇輕症病患啊如何避免啊今年醫院的總額比去年增加了370億欸那預期的點值穩定性會提升啊可是關鍵問題在如果避免影響民眾就醫的可進性和醫療品質很低啊但是有可能\n醫院我們健保多給了370億然後你們漲部分負擔也增加了醫院的收入然後呢如果再增加掛號費收入又要增加可是未來掛號掛不到然後檢查檢查不到然後未來看病的可靜性會受影響\n你有沒有可能面臨導致高醫療需求的病患不符但是不符合重症的範圍面臨更大的困難或者是變成全民搶掛號大賽大家都要搶掛號都拜託你不要搶掛號或是促使醫院策略性的選擇輕症病患平轉或上轉醫療資源耗用多的病患給其他公立的醫院進一步的加劇醫療資源分配不均\n然後再來第三點 郭年增教授講的醫院內部資源分配和管理衝突這不是醫病的問題 也不是醫院跟病人的問題而已光是醫院內部各分科的內部資源分配和管理就會產生衝突所以在某些科別好看的 成本低的 然後服務量增加\n然後薪資裡面呢 如果這種像成本高的不賺錢的科別 然後人數下降這邊看這個吃力不討好的 醫生會收入減成本高的 成本低的 然後好看的 人看越多越賺錢的 醫生薪水越來越高\n光是在這種狀況裡面醫師現有的薪酬制度除了兼行政主管或擔任研究醫師以外仍然都是以不拖你服務的量能為基礎鼓勵多做來分配酬勞和所得可是你當總額受到嚴格的控制然後醫院如果沒有有效的調整薪資激勵這個這個激勵的鼓勵的機制的話你如果反向的鼓勵不要充量然後你沒有鼓勵\n你這個管理食物上還有一種問題是論人記仇的狀況那你減少醫療你要讓這個醫生和部門之間真的啦這問題很嚴重的譬如說\n本醫來得住院 住院的我們都知道門診轉住院的病患病情比較穩定住院的天數容易管理比較有機會接受自費治療可是急重症的急診他轉住院的病患病情是相對嚴重的住院的時間也不確定的\n也可能比較容易被排擠有沒有可能在醫院的管理上他們在各部門的住院收留上寧可優先選擇收留門診轉上來的\n而策略性的將急重症的急診部門的要轉病房的讓他留在急診室導致急診有壓力進一步升高因為這部門和部門之間 我也要選定他要選勤課 他也要選籌檔的\n所以在這種狀況裡面這一類的急診和非急診專科的衝突在醫院裡面會不會被進一步的放大畢竟多收一個急診的患者即使能有健保的加成或是排除個別的總額之外相較於門診排成的住院病患哪一個比較符合他們那個部門的利益這個是很現實的因為那個部門也有護理人力缺護理師也考量到我寧可照顧\n門診轉上來誰要照顧那個急症急重症轉上來的所以為了在這種狀況裡面這個問題都是內部管理會衝突的而犧牲的是病人啦在這種狀況裡面還有一種病床控管的方式並不是由科部統一管理有一些醫院的病床的管理是根據個別醫師資歷去分配的\n而個別醫師的資歷的分配中它導致有空床仍然無法有效收治急診的病患所以在這裡我並不是說我們反對你分級醫療並不是說你反對你個別醫院的總額管制而是\n你要做的你要監測的更細緻你的配套機制要更完善而是你要預期到可能的衝擊對病人的衝擊是什麼而你的因應之道是什麼請問我剛剛講那些問題你們的配套是什麼\n病人受到這麼大的衝擊 你的配套是什麼所以在醫界 在學界人家已經跟你講你的政府要細緻的進行相關的監測和配套機制你講話怎麼這樣你們現在有什麼細緻的監測和配套機制你們監測的項目有哪些監測的頻率會如何設定監測後的檢討設定多久時間\n包園,你剛剛提的,不管是郭教授,或者是你提的寶貴的見解其實我們都知道我現在問你,你也在這裡,不是問你知不知道,我問你啊你現在監測的配套機制是什麼,你若不能說,叫你書長來說啦我看你是不會說啦,叫你書長來說你,謝謝記者,讓書長我問一下\n醫療可見性和品質的衝擊跟委員報告這個個別醫院總額除了台北區之外全部都在今年1月1號都實施了台北區當然是最困難的\n南區高屏區東區都已經早已實施多年所以這個不是一個新的制度因為這些問題在過去實施之前也都有這樣的疑慮但是實施下去之後我們各區的你不要這樣子好不好中南部的醫療現場的問題跟我們北區會一樣嗎\n一個大台北地區多少人你知道嗎大台北就好了北北基就好了多少人你告訴我700萬人啊但是大台北地區啊700萬在全台灣三分之一耶北北基而已耶\n你知道2004年就以醫院卓越計畫之名推行過了類似個別總額的制度了啦這個概念在2004年就做過了那因為部分醫院減少開立藥品種類和數量而且限制門診量導致民眾申訴掛不上號醫院減少開藥種類或數量甚至有醫學中心因為頻繁遭投訴而被中區健保業務組終止合約但是因為當時是自願參與的\n而未參加的醫院這個點子會讓他下降然後影響了整體醫療生態最後這一個計畫被監察院糾正欸那我不認為現在的計畫跟當時是一模一樣但是你們面對這個的態度你們認為台北的模式跟中南部會一樣都不會有問題學者專家叫你們監測什麼你們要監測了嗎\n有監測嗎 都會參考啦他們叫你監測什麼 你先回答我你先回答我 他們要求的監測合不合理他們要求監測什麼東西 你回答得出來嗎\n我們有很多的指標在檢測他在說你們都知道知道 你連聽都不想聽人家建議 監測實施前後的實施前後的門診和住院病患的屬性變化監測病人就醫流向是不是出現不合理的平轉或下轉引導醫院建立更合理的薪酬和資源分配機制\n引導醫院建立更合理的星球和資源分配機制你們的對策是什麼你們的手段 蘿蔔和棒子是什麼\n大家都轉到台大和北龍然後像那個人酬的話不收的話是要轉出那邊處分還是還是台大和北龍要負責我真的要語重心長的跟委員報告啦您的資料我們都會我們都了解也會解決但是我不是要來了解我現在問你說人家拋出來的問題\n他們絕對都是...我是幫醫院拋出來的問題拿來問你我不是在問醫院院長我擔心的是衛福部部長你要怎麼解決而你講不出來所以我擔心啦有蘿蔔有棍子但是不是一個學者所講的就代表全部\n我現在最好說一句啦現在我最好說一句啦 因為我說很久了啦你為大家不是靠上身就可以解決問題你不是大家叫你為上身就可以解決問題今天在這裡是說 人家提出問題了你有什麼看法 你有什麼解方你面對病人受到這麼大的衝擊 你的配套是什麼而今天\n而今天整個衛福部包括部長包括署長都對我們提出來的病人受到衝擊回答不出來不願意回答然後轉移焦點答非所問這才是大問題啦我們會解決所有的您擔心的問題大家宣誓性的唯獨一再的宣誓而已謝謝\n","vtt":"WEBVTT\n\n00:04.106 --> 00:07.387\n謝謝主席我們是不是請邱部長委員好部長好今天大家談了很多這個急診詠攝和護理人力的問題但我今天還是要繼續講這個\n\n00:25.726 --> 00:41.434\n大家都在談說這個病房護病比的限制護理人力的不足導致醫院這個關病房然後急診的住院帶床病人滯留狀況加劇那上次我也就教於你就是說光是減傷第一級的\n\n00:41.954 --> 01:08.095\n他的平均的流治的時間都超過標準時間8小時的還要到雙倍以上那我現在就請你看一個圖到底我們這個護理人力你對於平均媒體報導這個護理人力平均年齡39歲資深護理師留任這個健校你們自己是這樣講留任健校你是怎麼看待這個資訊的\n\n01:11.670 --> 01:28.445\n我是請那個市長先回答一下我是叫你看安安就是這樣講你自己發布的新聞你們自己的這個你自己都沒看過嗎就是說啊這個2024因為這個時候我還沒上任所以我要仔細看一下這樣子\n\n01:29.926 --> 01:47.137\n不是啊這是前幾天5月去年5月13號的新聞你還沒上任好那你知道這個議題也應該要了解一下吧因為我當然是希望護理師生能夠留任不是啦現在從一路早上大家問你都覺得說\n\n01:49.178 --> 02:06.031\n離職的雖然很多但你們12項政策要求穩定而且已經有見效增加的人力其實都是增加的雖然有離職的但你們剛才司長一直在講說人力普遍上還是增加的從你們的職登統計都看得出來那你們現在看出來數據我告訴你2021年護理師職業的平均年齡是36.95歲2024年是39.25歲\n\n02:17.879 --> 02:39.435\n那我就這樣子問你就好了就這件事情啦職業的平均年齡越來越增加你怎麼看待這一件事情平均職業年齡提高啊你怎麼看啊這可能要從兩個角度嘛\n\n02:42.048 --> 03:00.898\n因為當初去年你們認為這個是肯定把資深的留下來從這個角度來看也許是好事情那是不是說年輕的留不住也是一件事情這個可能要來看評但我們也很好奇為什麼年輕的因為我們開設多元的人才人力的培養\n\n03:01.718 --> 03:22.436\n包括學社後的護理系有持續的開設而且包括護理師的考試從一年兩次變成一年三次但我們的平均職業年齡卻節節攀升那你講的你也講了就是說啊這個留不住年輕的專業的護理人力那你知道部長你知道2012年台灣護理人員平均職業年齡是幾歲嗎2012年\n\n03:31.962 --> 03:40.613\n2012年啦你猜猜看你用猜的啦你們沒數據啦你用猜的你猜猜看好那多少歲被你偷看到了2012年29.6歲2024年39.25歲\n\n03:50.520 --> 03:54.883\n當時2012年2012年離現在並沒有很久你們專案報告是說平均年齡29歲而且21到30歲族群最多佔了43.6%43.6%都是30歲以下的護理人力而現在30歲以下護理人力可能是\n\n04:14.895 --> 04:31.866\n低的不像樣那你對這個數字其實你都沒有掌握我剛剛問你你也搞不清楚到底我們要肯定平均年齡39歲是留任成功還是說我們要擔心如果2012年平均年齡29歲2024年平均39歲如果照這個邏輯到2036年平均職業年齡會不會變成49歲有沒有可能是這樣子\n\n04:43.743 --> 04:53.728\n39歲留任都還留任成功我們很感謝這些資深的護理師扛起了這個責任可是呢我擔心的當然是年輕的子卿沒有進來\n\n04:55.100 --> 05:17.152\n年輕的族群沒進來可是我們的養成班開很多啊我們現在要問的是說剛剛已經有委員講了到澳洲年薪170萬到美國300萬起跳但都還要扣掉生活費那如果在這裡的待遇和工時能夠改善的話大家都知道說大家如果可以留在自己的家鄉誰願意遠離故鄉呢\n\n05:20.854 --> 05:42.865\n不是了解而已你們開源人數理論上是增加的取得證照的人數也越來越多可是我們平均職業年齡卻越來越高這是不合理的這種狀況裡面畢業生不來心血留不住資深扛起來然後病房關床急診永設一環扣一環\n\n05:45.159 --> 05:51.601\n這些畢業生留到外國去難道台灣是要幫變成一個國際護理師的執訓中心嗎台灣護理人才的養成是要幫國際的護理人員變成後備養成中心嗎\n\n06:02.332 --> 06:27.762\n我們很希望我們培養出來的都能夠留在國內因為國內還是需要這些人才我們想盡辦法把他留在國內所以我們現在是政策規劃是有問題還是政策規劃不利還是執行面有問題所以在這種狀況裡面不要動不動就覺得說你們市長剛剛講說我們人數是增加的人數增加都資深的年輕的優秀的沒有心血進來\n\n06:29.062 --> 06:38.220\n所以你的KPI應該是護理人員回流多少病床開床率是多少而不是在這裡說你有增加可是結果病床關的越多急診越湧射\n\n06:41.366 --> 06:51.175\n現在護理人員講啊如果是醫生或醫院跟你們反映問題你們都馬上回應有所回應護理人力跟你們反映問題護理工會跟你們反映問題你們毫無感覺只好護理人員用集體離職來跟你們做無聲的抗議\n\n07:02.322 --> 07:30.499\n現在是人家反映了你們對於護理人員跟對於醫師跟對醫院他們講話的份量不一樣啊份量不一樣只好用離職來告訴你他抗議這是大問題捏不對嗎要怎麼走要怎麼走你的12項政策政策工具現在好像也是留住資深的而已資深的而已\n\n07:31.636 --> 07:53.289\n我們很希望因為一進來他工作是不是滿意新手啦新手其實是非常重要的所以我們有這個護理新手的臨床導師好啦我希望半年後你來告訴我你十二項政策讓年輕的護理師願意留下來為台灣的病患服務我們前一步\n\n07:55.624 --> 08:09.412\n半年後我會再問你喔就不要再講半年前我問你的這個醫院有公安危機的你還沒告訴我還沒回答我喔當然我今天還有更重要的要問你就是因為有這個問題以外還有\n\n08:12.074 --> 08:39.803\n今年實施的醫院個別總額制的問題在第二季要上路了醫院個別總額制的問題啊你們有一個很有效的打擊醫療人球的策略和方案那你有很有效的羅伯安棒子你知道總額健保總額增加了700多億醫院增加了300多億吧至少醫院拿走了一半以上吧\n\n08:41.344 --> 08:42.288\n那一人\n\n08:43.539 --> 09:10.637\n拿多了幾百億的錢出來可是醫院就這樣子急診永設然後現在關病床這已經是夠荒謬夠好笑了我今年要給你三四百億結果關了病床更多結果急診更永設然後你說你有一個醫療人球的這個應對的這個策略這樣子那我現在問你喔就是說啊你有沒有盤點到\n\n09:14.396 --> 09:16.862\n這個未來醫院個別總額制醫療現場會面臨哪一些衝擊\n\n09:23.066 --> 09:44.202\n阿你又有什麼因應的策略我可不可以分兩段來報告一下因為我們所有今年的預算都還沒有setdown所以還沒有開始來來能夠去落實各種不管是醫院基層相關包括這個年負病比的獎金現在都還沒有開始來發我想希望能夠\n\n09:45.663 --> 09:53.188\n預算這個會計都能夠趕快做完你現在是在說什麼說什麼個別醫院總額次啊對你個別醫院總額我們當然知道個別醫院總額是這樣子在台北區也是第二劑才會開始所以你個別醫院總額也是第二劑才要開始啊台北區現在所發生的醫院用色的問題\n\n10:07.407 --> 10:12.511\n當然應該是還沒有我沒有在問你這個我現在問你是說那個別醫院總額的話我們當然你這樣子實施這個醫院個別總額制實行下去以後醫療現場會發生什麼樣的變化那看病的民眾會受到什麼衝擊我現在是在問這個啊了解\n\n10:27.222 --> 10:33.608\n我是站在病人和人民的立場在問這個我想這個也不是說突然要去做不是啦會有什麼衝擊你怎麼講不出來沒關係我沒有管你我沒有突然而且我也不見得說認為這樣子是錯的我不認為這樣子就一定是不行的\n\n10:46.518 --> 11:06.362\n但我現在問你是說有可能面臨到看病的人會受到的衝擊是什麼你來告訴我因為你告訴我了所以你才有想說你的因應策略是什麼那證明你每一個政策新的政策的施行都是有評估有步驟而且到最後的衝擊你們也有因應的策略的我是要看到這個過程啊所以我現在問你\n\n11:13.599 --> 11:15.882\n這樣子新的制度上路你有沒有盤點過醫療現場會面臨什麼衝擊\n\n11:20.310 --> 11:41.655\n第一個是什麼我想醫院在財務的自我管理會更加的一個謹慎那如果說他的管理他對病人就會用最有效益的方式來解決你可不可以講具體一點啊不然我說給你聽你補正耶不然我說給你聽啦我再舉個例子他的大姨的日子\n\n11:44.496 --> 11:53.681\n聽你講這個我認為你不使人間煙火因為很多醫院都跳出來反應了很多醫院的發言人都出來講話了第一個根據媒體的報導台大\n\n11:59.864 --> 12:27.861\n民眾最擔心的就是醫學中心掛號費會不會調漲然後呢台大醫院目前掛號費100健保部分負擔420然後呢發言人就表示各種醫療支出要價不斷攀升去年點值不到0.9仍然遠遠的趕不上高漲的電費人事費為了因應可能的財務衝擊他們已經商量很多了然後他們不排除最後一個就是調漲掛號費\n\n12:29.762 --> 12:49.176\n然後新光醫院的副院長大家都知道醫務管理學會的理事長洪子仁也表示不過他們講的更多他們盤點醫院量能他們能做的調控措施包括調高掛費以外減少週六及夜間門診控制掛號人數延後非緊急手術等等\n\n12:56.254 --> 12:57.537\n現在這事情有嚴重嗎?我現在講這個可能的衝擊在這裡生病的人會受到的衝擊\n\n13:06.408 --> 13:26.785\n那錢會開過的還算是最小的調高掛號費再來開集也不會開過的週末假日還有夜間門診減少了開集要去掛號又掛不到了控制掛號人數你要去看也掛不到了半夜的週末的集中症的\n\n13:28.387 --> 13:40.095\n延後非緊急手術那意思是說都要碰瓶子那瓶子不上不下集中症當然排除在那個外面啦但是呢還有一種是減傷\n\n13:42.920 --> 13:48.205\n輕的報重的這也不可能啊當然這種狀況調整掛號費還掛不到號這民怨四起啊對民眾來講可能衝擊到醫療品質掛號看診困難自費項目變多手術被延後然後消基會的董事吳榮達他擔憂啊\n\n14:03.599 --> 14:08.801\n這一個新制上路醫療品質會下降醫院如果縮門診量民眾掛號看診更困難影響就醫的可敬性當然我們希望分級醫療所以這個縮門診量是對是錯我們暫姑且不論但是這個蕭紀惠董事會講就檢驗檢查手術時間的遞延也會影響病情的發現導致病情惡化\n\n14:31.750 --> 14:44.834\n如果醫院若自行限縮醫療服務的申報門診檢查檢驗手術住院減少可能會影響這個事情再來喔醫療人員的收入加劇人力的出走這你們有想過嗎\n\n14:48.720 --> 15:02.766\n你知不知道不是我們不支持分級醫療有時候到小診所然後醫生檢查不出問題都會叫我們說你為了慎重起見到醫學中心去做檢查有沒有這種狀況\n\n15:04.148 --> 15:11.275\n有啊很多啊還有一個根據媒體報導56歲的楊女士服用高血壓的藥6年照都在台中榮總心臟內科定期回診拿單然後呢她也不懂什麼是腫瘀然後為了要掛號她覺得掛號費漲她會吞下去但是她曾經因為服用醫院給的藥不要忘了你們還有缺藥的問題喔\n\n15:29.591 --> 15:42.115\n你們缺藥的問題尤其是一些特殊的藥只有供給給醫院沒有供給給地區醫院也沒有供給給地方診所也沒有供給給地區的藥房結果他說他的經驗是他病情穩定了醫院將他下轉到診所\n\n15:47.196 --> 16:02.761\n從診所從原廠藥變學名藥還需要在醫學中心回診已經每半年都抽血檢驗看這個一下在診所檢驗又要回到醫學中心就算了但是呢後來檢查好以後他有時候又要到發現變嚴重了又要到中榮去就診\n\n16:09.810 --> 16:24.728\n這個我們要講的是說分級是對的但是有很多狀況並不是民眾迷信醫學醫院或教學中心而是事情的原本就是這樣直接治療好控制好你叫我去診所就控制不好我就要回來\n\n16:26.471 --> 16:39.144\n這個教學中心所以這個很複雜的不一定大家都喜歡逛醫院也不一定大家都認為到醫學中心好可是他的經驗就是如此所以他覺得說這個狀況怎麼處理呢你不可以僅憑政策的調整或是你們從上面講說就是這樣子沒問題可以改變了\n\n16:47.552 --> 16:52.415\n你要去掌握民眾的就醫習慣和決策的行為這是很複雜的你單純調高掛號費也不代表能夠有效的降低民眾因輕症前往醫學中心的就診的狀況這個我也質詢過你調整了部分負擔結果呢結果呢到醫學中心裡面看病的看門診的量增加增加\n\n17:17.072 --> 17:24.080\n現在只有改變什麼從人民的荷包掏出更多錢這一件事情而已你想要做的分級醫療沒有改變你當初漲部分負擔就說是為了要落實分級醫療結果沒有辦法控制啊\n\n17:32.088 --> 17:34.289\n無效啊無效的政策啊那現在呢醫改會也擔心啦門診減量以後醫院可能會透過健保轉資費減少賣信簽的處方簽的釋出調漲掛號費來增加收入導致病人看病變貴\n\n17:50.558 --> 18:07.904\n那為了讓治療項目得到保障甚至可能會將輕症報為重症那為了避免過度申報而斷頭給付他也可能會發展什麼我報太多被斷頭給付那他要怎麼因應如果你是醫院接應者你要怎麼因應部長\n\n18:09.822 --> 18:25.468\n真的很敬佩委員你覺得他們上有政策下有對策你覺得醫院會怎麼因應啊他是非常複雜的因素但是我必須要跟大家講說今天我們生活在台灣這個國度是非常幸福的\n\n18:25.828 --> 18:34.812\n我現在要跟你說你的政策有問題沒有啦我投資你政策可能的問題在哪裡沒有啦你講不出來我就告訴你啦醫院你一直去看他沒有辦法負責別人我們一定要改革讓他練保養讓永遠得到好的照顧\n\n18:51.940 --> 19:20.297\n我不叫你回答,你一直跟我相親,我要跟你說,北醫要面對這麼多人來看診,他怎麼因應,上有政策下有對策道高於尺,魔高於杖啦北醫要透過門前診所啦將輕症帶出醫院治療啦而門前診所已經很多了,很普遍啦這個就是我們在集合的重點之一集合的重點之一有改變嗎?\n\n19:21.567 --> 19:50.454\n有解決嗎我們各區的管理在這個部分沒有啦將輕症帶出醫院假裝不是醫院去看的門前診所然後再去瓜分西醫的基層診所的總額從醫院的總額再來瓜分診所的總額而重症的病人如果沒有人要收通通給他送到公立醫院讓護理人力更慌公立醫院的\n\n19:51.434 --> 20:04.025\n所以如果避免醫院選病人你衝擊的配套在哪裡如果讓人家剛提出來的可能的問題你們是有能力因應的嗎你來告訴我\n\n20:05.643 --> 20:22.818\n透過健保轉資費你要怎麼處理減少慢性遷的事數你要怎麼處理調漲掛號費但是沒有改善醫療分級的問題你怎麼處理門前診所你說你要列為評鑑的項目但是你沒有效你要怎麼處理我們委員所擔心所提出的請你放心\n\n20:29.319 --> 20:48.911\n我們一定一個一個去把它監測還有呢保障人權最佳的政府限縮門診你知道台大你們台大健康政策管理研究所門診的數量真的不用太重我現在不跟你說了我現在不請你講你之前在這裡說的黃正熙教授有要替我看其實大家都看了沒有啦我現在沒有在提你台港主席我要問問題他這樣子一直台港我怎麼問\n\n20:57.856 --> 21:10.499\n我是說台大健康政策管理研究所的副教授郭年珍他最近也撰文指出個別醫院總額上路會遇到的四個問題第一個限縮門診手術是否會影響就醫的限縮門診和手術會不會影響到就醫的可進性\n\n21:18.041 --> 21:35.737\n那第二個就是說啊如何避免醫療醫院選擇輕症病患啊如何避免啊今年醫院的總額比去年增加了370億欸那預期的點值穩定性會提升啊可是關鍵問題在如果避免影響民眾就醫的可進性和醫療品質很低啊但是有可能\n\n21:43.781 --> 22:03.394\n醫院我們健保多給了370億然後你們漲部分負擔也增加了醫院的收入然後呢如果再增加掛號費收入又要增加可是未來掛號掛不到然後檢查檢查不到然後未來看病的可靜性會受影響\n\n22:04.855 --> 22:33.422\n你有沒有可能面臨導致高醫療需求的病患不符但是不符合重症的範圍面臨更大的困難或者是變成全民搶掛號大賽大家都要搶掛號都拜託你不要搶掛號或是促使醫院策略性的選擇輕症病患平轉或上轉醫療資源耗用多的病患給其他公立的醫院進一步的加劇醫療資源分配不均\n\n22:35.370 --> 23:00.423\n然後再來第三點郭年增教授講的醫院內部資源分配和管理衝突這不是醫病的問題也不是醫院跟病人的問題而已光是醫院內部各分科的內部資源分配和管理就會產生衝突所以在某些科別好看的成本低的然後服務量增加\n\n23:01.443 --> 23:14.166\n然後薪資裡面呢如果這種像成本高的不賺錢的科別然後人數下降這邊看這個吃力不討好的醫生會收入減成本高的成本低的然後好看的人看越多越賺錢的醫生薪水越來越高\n\n23:22.228 --> 23:50.404\n光是在這種狀況裡面醫師現有的薪酬制度除了兼行政主管或擔任研究醫師以外仍然都是以不拖你服務的量能為基礎鼓勵多做來分配酬勞和所得可是你當總額受到嚴格的控制然後醫院如果沒有有效的調整薪資激勵這個這個激勵的鼓勵的機制的話你如果反向的鼓勵不要充量然後你沒有鼓勵\n\n23:51.405 --> 23:52.286\n你這個管理食物上還有一種問題是論人記仇的狀況那你減少醫療你要讓這個醫生和部門之間真的啦這問題很嚴重的譬如說\n\n24:10.475 --> 24:30.796\n本醫來得住院住院的我們都知道門診轉住院的病患病情比較穩定住院的天數容易管理比較有機會接受自費治療可是急重症的急診他轉住院的病患病情是相對嚴重的住院的時間也不確定的\n\n24:32.498 --> 24:37.764\n也可能比較容易被排擠有沒有可能在醫院的管理上他們在各部門的住院收留上寧可優先選擇收留門診轉上來的\n\n24:47.435 --> 24:59.205\n而策略性的將急重症的急診部門的要轉病房的讓他留在急診室導致急診有壓力進一步升高因為這部門和部門之間我也要選定他要選勤課他也要選籌檔的\n\n25:07.173 --> 25:36.029\n所以在這種狀況裡面這一類的急診和非急診專科的衝突在醫院裡面會不會被進一步的放大畢竟多收一個急診的患者即使能有健保的加成或是排除個別的總額之外相較於門診排成的住院病患哪一個比較符合他們那個部門的利益這個是很現實的因為那個部門也有護理人力缺護理師也考量到我寧可照顧\n\n25:36.869 --> 25:40.212\n門診轉上來誰要照顧那個急症急重症轉上來的所以為了在這種狀況裡面這個問題都是內部管理會衝突的而犧牲的是病人啦在這種狀況裡面還有一種病床控管的方式並不是由科部統一管理有一些醫院的病床的管理是根據個別醫師資歷去分配的\n\n26:03.717 --> 26:19.807\n而個別醫師的資歷的分配中它導致有空床仍然無法有效收治急診的病患所以在這裡我並不是說我們反對你分級醫療並不是說你反對你個別醫院的總額管制而是\n\n26:21.257 --> 26:36.305\n你要做的你要監測的更細緻你的配套機制要更完善而是你要預期到可能的衝擊對病人的衝擊是什麼而你的因應之道是什麼請問我剛剛講那些問題你們的配套是什麼\n\n26:41.547 --> 26:55.238\n病人受到這麼大的衝擊你的配套是什麼所以在醫界在學界人家已經跟你講你的政府要細緻的進行相關的監測和配套機制你講話怎麼這樣你們現在有什麼細緻的監測和配套機制你們監測的項目有哪些監測的頻率會如何設定監測後的檢討設定多久時間\n\n27:07.984 --> 27:23.915\n包園,你剛剛提的,不管是郭教授,或者是你提的寶貴的見解其實我們都知道我現在問你,你也在這裡,不是問你知不知道,我問你啊你現在監測的配套機制是什麼,你若不能說,叫你書長來說啦我看你是不會說啦,叫你書長來說你,謝謝記者,讓書長我問一下\n\n27:34.679 --> 27:46.489\n醫療可見性和品質的衝擊跟委員報告這個個別醫院總額除了台北區之外全部都在今年1月1號都實施了台北區當然是最困難的\n\n27:48.371 --> 27:53.493\n南區高屏區東區都已經早已實施多年所以這個不是一個新的制度因為這些問題在過去實施之前也都有這樣的疑慮但是實施下去之後我們各區的你不要這樣子好不好中南部的醫療現場的問題跟我們北區會一樣嗎\n\n28:12.760 --> 28:24.732\n一個大台北地區多少人你知道嗎大台北就好了北北基就好了多少人你告訴我700萬人啊但是大台北地區啊700萬在全台灣三分之一耶北北基而已耶\n\n28:29.929 --> 28:57.723\n你知道2004年就以醫院卓越計畫之名推行過了類似個別總額的制度了啦這個概念在2004年就做過了那因為部分醫院減少開立藥品種類和數量而且限制門診量導致民眾申訴掛不上號醫院減少開藥種類或數量甚至有醫學中心因為頻繁遭投訴而被中區健保業務組終止合約但是因為當時是自願參與的\n\n28:59.884 --> 29:26.143\n而未參加的醫院這個點子會讓他下降然後影響了整體醫療生態最後這一個計畫被監察院糾正欸那我不認為現在的計畫跟當時是一模一樣但是你們面對這個的態度你們認為台北的模式跟中南部會一樣都不會有問題學者專家叫你們監測什麼你們要監測了嗎\n\n29:29.105 --> 29:35.870\n有監測嗎都會參考啦他們叫你監測什麼你先回答我你先回答我他們要求的監測合不合理他們要求監測什麼東西你回答得出來嗎\n\n29:46.277 --> 30:14.966\n我們有很多的指標在檢測他在說你們都知道知道你連聽都不想聽人家建議監測實施前後的實施前後的門診和住院病患的屬性變化監測病人就醫流向是不是出現不合理的平轉或下轉引導醫院建立更合理的薪酬和資源分配機制\n\n30:16.363 --> 30:24.930\n引導醫院建立更合理的星球和資源分配機制你們的對策是什麼你們的手段蘿蔔和棒子是什麼\n\n30:29.793 --> 30:49.010\n大家都轉到台大和北龍然後像那個人酬的話不收的話是要轉出那邊處分還是還是台大和北龍要負責我真的要語重心長的跟委員報告啦您的資料我們都會我們都了解也會解決但是我不是要來了解我現在問你說人家拋出來的問題\n\n30:51.932 --> 31:12.364\n他們絕對都是...我是幫醫院拋出來的問題拿來問你我不是在問醫院院長我擔心的是衛福部部長你要怎麼解決而你講不出來所以我擔心啦有蘿蔔有棍子但是不是一個學者所講的就代表全部\n\n31:13.044 --> 31:18.666\n我現在最好說一句啦現在我最好說一句啦因為我說很久了啦你為大家不是靠上身就可以解決問題你不是大家叫你為上身就可以解決問題今天在這裡是說人家提出問題了你有什麼看法你有什麼解方你面對病人受到這麼大的衝擊你的配套是什麼而今天\n\n31:41.713 --> 32:03.559\n而今天整個衛福部包括部長包括署長都對我們提出來的病人受到衝擊回答不出來不願意回答然後轉移焦點答非所問這才是大問題啦我們會解決所有的您擔心的問題大家宣誓性的唯獨一再的宣誓而已謝謝\n\n","segments":[{"start":4.106,"end":7.387,"text":"謝謝主席我們是不是請邱部長委員好部長好今天大家談了很多這個急診詠攝和護理人力的問題但我今天還是要繼續講這個"},{"start":25.726,"end":41.434,"text":"大家都在談說這個病房護病比的限制護理人力的不足導致醫院這個關病房然後急診的住院帶床病人滯留狀況加劇那上次我也就教於你就是說光是減傷第一級的"},{"start":41.954,"end":68.095,"text":"他的平均的流治的時間都超過標準時間8小時的還要到雙倍以上那我現在就請你看一個圖到底我們這個護理人力你對於平均媒體報導這個護理人力平均年齡39歲資深護理師留任這個健校你們自己是這樣講留任健校你是怎麼看待這個資訊的"},{"start":71.67,"end":88.445,"text":"我是請那個市長先回答一下我是叫你看安安就是這樣講你自己發布的新聞你們自己的這個你自己都沒看過嗎就是說啊這個2024因為這個時候我還沒上任所以我要仔細看一下這樣子"},{"start":89.926,"end":107.137,"text":"不是啊這是前幾天5月去年5月13號的新聞你還沒上任好那你知道這個議題也應該要了解一下吧因為我當然是希望護理師生能夠留任不是啦現在從一路早上大家問你都覺得說"},{"start":109.178,"end":126.031,"text":"離職的雖然很多但你們12項政策要求穩定而且已經有見效增加的人力其實都是增加的雖然有離職的但你們剛才司長一直在講說人力普遍上還是增加的從你們的職登統計都看得出來那你們現在看出來數據我告訴你2021年護理師職業的平均年齡是36.95歲2024年是39.25歲"},{"start":137.879,"end":159.435,"text":"那我就這樣子問你就好了 就這件事情啦職業的平均年齡越來越增加 你怎麼看待這一件事情平均職業年齡提高啊你怎麼看啊這可能要從兩個角度嘛"},{"start":162.048,"end":180.898,"text":"因為當初去年你們認為這個是肯定把資深的留下來從這個角度來看也許是好事情那是不是說年輕的留不住也是一件事情這個可能要來看評但我們也很好奇為什麼年輕的因為我們開設多元的人才人力的培養"},{"start":181.718,"end":202.436,"text":"包括學社後的護理系有持續的開設而且包括護理師的考試從一年兩次變成一年三次但我們的平均職業年齡卻節節攀升那你講的你也講了就是說啊這個留不住年輕的專業的護理人力那你知道部長你知道2012年台灣護理人員平均職業年齡是幾歲嗎2012年"},{"start":211.962,"end":220.613,"text":"2012年啦 你猜猜看 你用猜的啦 你們沒數據啦 你用猜的 你猜猜看好 那多少歲 被你偷看到了2012年29.6歲 2024年39.25歲"},{"start":230.52,"end":234.883,"text":"當時2012年2012年離現在並沒有很久你們專案報告是說平均年齡29歲而且21到30歲族群最多佔了43.6%43.6%都是30歲以下的護理人力而現在30歲以下護理人力可能是"},{"start":254.895,"end":271.866,"text":"低的不像樣那你對這個數字其實你都沒有掌握我剛剛問你 你也搞不清楚到底我們要肯定平均年齡39歲是留任成功還是說我們要擔心如果2012年平均年齡29歲2024年平均39歲如果照這個邏輯到2036年平均職業年齡會不會變成49歲有沒有可能是這樣子"},{"start":283.743,"end":293.728,"text":"39歲留任都還留任成功我們很感謝這些資深的護理師扛起了這個責任可是呢我擔心的當然是年輕的子卿沒有進來"},{"start":295.1,"end":317.152,"text":"年輕的族群沒進來可是我們的養成班開很多啊我們現在要問的是說剛剛已經有委員講了到澳洲年薪170萬到美國300萬起跳但都還要扣掉生活費那如果在這裡的待遇和工時能夠改善的話大家都知道說大家如果可以留在自己的家鄉誰願意遠離故鄉呢"},{"start":320.854,"end":342.865,"text":"不是了解而已你們開源人數理論上是增加的取得證照的人數也越來越多可是我們平均職業年齡卻越來越高這是不合理的這種狀況裡面畢業生不來心血留不住資深扛起來然後病房關床急診永設一環扣一環"},{"start":345.159,"end":351.601,"text":"這些畢業生留到外國去難道台灣是要幫變成一個國際護理師的執訓中心嗎台灣護理人才的養成是要幫國際的護理人員變成後備養成中心嗎"},{"start":362.332,"end":387.762,"text":"我們很希望我們培養出來的都能夠留在國內因為國內還是需要這些人才我們想盡辦法把他留在國內所以我們現在是政策規劃是有問題還是政策規劃不利還是執行面有問題所以在這種狀況裡面不要動不動就覺得說你們市長剛剛講說我們人數是增加的人數增加都資深的年輕的優秀的沒有心血進來"},{"start":389.062,"end":398.22,"text":"所以你的KPI應該是護理人員回流多少病床開床率是多少而不是在這裡說你有增加可是結果病床關的越多急診越湧射"},{"start":401.366,"end":411.175,"text":"現在護理人員講啊 如果是醫生或醫院跟你們反映問題 你們都馬上回應有所回應 護理人力跟你們反映問題 護理工會跟你們反映問題你們毫無感覺 只好護理人員用集體離職來跟你們做無聲的抗議"},{"start":422.322,"end":450.499,"text":"現在是人家反映了你們對於護理人員跟對於醫師跟對醫院他們講話的份量不一樣啊份量不一樣只好用離職來告訴你他抗議這是大問題捏不對嗎要怎麼走要怎麼走你的12項政策政策工具現在好像也是留住資深的而已資深的而已"},{"start":451.636,"end":473.289,"text":"我們很希望因為一進來他工作是不是滿意新手啦新手其實是非常重要的所以我們有這個護理新手的臨床導師好啦我希望半年後你來告訴我你十二項政策讓年輕的護理師願意留下來為台灣的病患服務我們前一步"},{"start":475.624,"end":489.412,"text":"半年後我會再問你喔就不要再講半年前我問你的這個醫院有公安危機的你還沒告訴我還沒回答我喔當然我今天還有更重要的要問你就是因為有這個問題以外還有"},{"start":492.074,"end":519.803,"text":"今年實施的醫院個別總額制的問題在第二季要上路了醫院個別總額制的問題啊你們有一個很有效的打擊醫療人球的策略和方案那你有很有效的羅伯安棒子你知道總額健保總額增加了700多億醫院增加了300多億吧至少醫院拿走了一半以上吧"},{"start":521.344,"end":522.288,"text":"那一人"},{"start":523.539,"end":550.637,"text":"拿多了幾百億的錢出來可是醫院就這樣子急診永設然後現在關病床這已經是夠荒謬 夠好笑了我今年要給你三四百億結果關了病床更多結果急診更永設然後你說你有一個醫療人球的這個應對的這個策略這樣子那我現在問你喔 就是說啊你有沒有盤點到"},{"start":554.396,"end":556.862,"text":"這個未來醫院個別總額制醫療現場會面臨哪一些衝擊"},{"start":563.066,"end":584.202,"text":"阿你又有什麼因應的策略我可不可以分兩段來報告一下因為我們所有今年的預算都還沒有set down所以還沒有開始來來能夠去落實各種不管是醫院基層相關包括這個年負病比的獎金現在都還沒有開始來發我想希望能夠"},{"start":585.663,"end":593.188,"text":"預算這個會計都能夠趕快做完你現在是在說什麼 說什麼個別醫院總額次啊對你個別醫院總額我們當然知道個別醫院總額是這樣子在台北區也是第二劑才會開始所以你個別醫院總額也是第二劑才要開始啊台北區現在所發生的醫院用色的問題"},{"start":607.407,"end":612.511,"text":"當然應該是還沒有我沒有在問你這個我現在問你是說那個別醫院總額的話我們當然你這樣子實施這個醫院個別總額制實行下去以後醫療現場會發生什麼樣的變化那看病的民眾會受到什麼衝擊我現在是在問這個啊了解"},{"start":627.222,"end":633.608,"text":"我是站在病人和人民的立場在問這個我想這個也不是說突然要去做不是啦會有什麼衝擊你怎麼講不出來沒關係我沒有管你我沒有突然而且我也不見得說認為這樣子是錯的我不認為這樣子就一定是不行的"},{"start":646.518,"end":666.362,"text":"但我現在問你是說有可能面臨到看病的人會受到的衝擊是什麼你來告訴我因為你告訴我了所以你才有想說你的因應策略是什麼那證明你每一個政策新的政策的施行都是有評估有步驟而且到最後的衝擊你們也有因應的策略的我是要看到這個過程啊所以我現在問你"},{"start":673.599,"end":675.882,"text":"這樣子新的制度上路你有沒有盤點過醫療現場會面臨什麼衝擊"},{"start":680.31,"end":701.655,"text":"第一個是什麼我想醫院在財務的自我管理會更加的一個謹慎那如果說他的管理他對病人就會用最有效益的方式來解決你可不可以講具體一點啊不然我說給你聽你補正耶不然我說給你聽啦我再舉個例子他的大姨的日子"},{"start":704.496,"end":713.681,"text":"聽你講這個我認為你不使人間煙火因為很多醫院都跳出來反應了很多醫院的發言人都出來講話了第一個根據媒體的報導台大"},{"start":719.864,"end":747.861,"text":"民眾最擔心的就是醫學中心掛號費會不會調漲然後呢台大醫院目前掛號費100健保部分負擔420然後呢發言人就表示各種醫療支出要價不斷攀升去年點值不到0.9仍然遠遠的趕不上高漲的電費人事費為了因應可能的財務衝擊他們已經商量很多了然後他們不排除最後一個就是調漲掛號費"},{"start":749.762,"end":769.176,"text":"然後新光醫院的副院長大家都知道醫務管理學會的理事長洪子仁也表示不過他們講的更多他們盤點醫院量能他們能做的調控措施包括調高掛費以外減少週六及夜間門診控制掛號人數延後非緊急手術等等"},{"start":776.254,"end":777.537,"text":"現在這事情有嚴重嗎?我現在講這個可能的衝擊在這裡生病的人會受到的衝擊"},{"start":786.408,"end":806.785,"text":"那錢會開過的還算是最小的 調高掛號費再來開集也不會開過的週末假日還有夜間門診減少了開集要去掛號又掛不到了控制掛號人數你要去看也掛不到了半夜的週末的集中症的"},{"start":808.387,"end":820.095,"text":"延後非緊急手術那意思是說都要碰瓶子那瓶子不上不下集中症當然排除在那個外面啦但是呢還有一種是減傷"},{"start":822.92,"end":828.205,"text":"輕的報重的 這也不可能啊當然這種狀況 調整掛號費還掛不到號 這民怨四起啊對民眾來講 可能衝擊到醫療品質 掛號看診困難自費項目變多 手術被延後然後消基會的董事吳榮達 他擔憂啊"},{"start":843.599,"end":848.801,"text":"這一個新制上路醫療品質會下降醫院如果縮門診量民眾掛號看診更困難影響就醫的可敬性當然我們希望分級醫療所以這個縮門診量是對是錯我們暫姑且不論但是這個蕭紀惠董事會講就檢驗檢查手術時間的遞延也會影響病情的發現導致病情惡化"},{"start":871.75,"end":884.834,"text":"如果醫院若自行限縮醫療服務的申報門診檢查檢驗手術住院減少可能會影響這個事情再來喔醫療人員的收入加劇人力的出走這你們有想過嗎"},{"start":888.72,"end":902.766,"text":"你知不知道不是我們不支持分級醫療有時候到小診所然後醫生檢查不出問題都會叫我們說你為了慎重起見到醫學中心去做檢查有沒有這種狀況"},{"start":904.148,"end":911.275,"text":"有啊很多啊還有一個根據媒體報導56歲的楊女士服用高血壓的藥6年照都在台中榮總心臟內科定期回診拿單然後呢她也不懂什麼是腫瘀然後為了要掛號她覺得掛號費漲她會吞下去但是她曾經因為服用醫院給的藥不要忘了你們還有缺藥的問題喔"},{"start":929.591,"end":942.115,"text":"你們缺藥的問題尤其是一些特殊的藥只有供給給醫院沒有供給給地區醫院也沒有供給給地方診所也沒有供給給地區的藥房結果他說他的經驗是他病情穩定了醫院將他下轉到診所"},{"start":947.196,"end":962.761,"text":"從診所 從原廠藥變學名藥還需要在醫學中心回診 已經每半年都抽血檢驗看這個一下在診所 檢驗又要回到醫學中心就算了但是呢 後來 檢查好以後 他有時候又要到發現變嚴重了 又要到中榮去就診"},{"start":969.81,"end":984.728,"text":"這個我們要講的是說分級是對的但是有很多狀況並不是民眾迷信醫學醫院或教學中心而是事情的原本就是這樣直接治療好控制好你叫我去診所就控制不好我就要回來"},{"start":986.471,"end":999.144,"text":"這個教學中心所以這個很複雜的不一定大家都喜歡逛醫院也不一定大家都認為到醫學中心好可是他的經驗就是如此所以他覺得說這個狀況怎麼處理呢你不可以僅憑政策的調整或是你們從上面講說就是這樣子沒問題可以改變了"},{"start":1007.552,"end":1012.415,"text":"你要去掌握民眾的就醫習慣和決策的行為這是很複雜的你單純調高掛號費也不代表能夠有效的降低民眾因輕症前往醫學中心的就診的狀況這個我也質詢過你調整了部分負擔結果呢結果呢 到醫學中心裡面看病的 看門診的量增加 增加"},{"start":1037.072,"end":1044.08,"text":"現在只有改變什麼從人民的荷包掏出更多錢這一件事情而已你想要做的分級醫療沒有改變你當初漲部分負擔就說是為了要落實分級醫療結果沒有辦法控制啊"},{"start":1052.088,"end":1054.289,"text":"無效啊 無效的政策啊那現在呢醫改會也擔心啦門診減量以後醫院可能會透過健保轉資費減少賣信簽的處方簽的釋出調漲掛號費來增加收入導致病人看病變貴"},{"start":1070.558,"end":1087.904,"text":"那為了讓治療項目得到保障甚至可能會將輕症報為重症那為了避免過度申報而斷頭給付他也可能會發展什麼我報太多被斷頭給付那他要怎麼因應如果你是醫院接應者你要怎麼因應部長"},{"start":1089.822,"end":1105.468,"text":"真的很敬佩委員你覺得他們上有政策下有對策你覺得醫院會怎麼因應啊他是非常複雜的因素但是我必須要跟大家講說今天我們生活在台灣這個國度是非常幸福的"},{"start":1105.828,"end":1114.812,"text":"我現在要跟你說你的政策有問題沒有啦我投資你政策可能的問題在哪裡沒有啦你講不出來我就告訴你啦醫院你一直去看他沒有辦法負責別人我們一定要改革讓他練保養讓永遠得到好的照顧"},{"start":1131.94,"end":1160.297,"text":"我不叫你回答,你一直跟我相親,我要跟你說,北醫要面對這麼多人來看診,他怎麼因應,上有政策下有對策道高於尺,魔高於杖啦北醫要透過門前診所啦將輕症帶出醫院治療啦而門前診所已經很多了,很普遍啦這個就是我們在集合的重點之一集合的重點之一有改變嗎?"},{"start":1161.567,"end":1190.454,"text":"有解決嗎我們各區的管理在這個部分沒有啦將輕症帶出醫院假裝不是醫院去看的門前診所然後再去瓜分西醫的基層診所的總額從醫院的總額再來瓜分診所的總額而重症的病人如果沒有人要收通通給他送到公立醫院讓護理人力更慌公立醫院的"},{"start":1191.434,"end":1204.025,"text":"所以如果避免醫院選病人你衝擊的配套在哪裡如果讓人家剛提出來的可能的問題你們是有能力因應的嗎你來告訴我"},{"start":1205.643,"end":1222.818,"text":"透過健保轉資費你要怎麼處理減少慢性遷的事數你要怎麼處理調漲掛號費但是沒有改善醫療分級的問題你怎麼處理門前診所你說你要列為評鑑的項目但是你沒有效你要怎麼處理我們委員所擔心所提出的請你放心"},{"start":1229.319,"end":1248.911,"text":"我們一定一個一個去把它監測還有呢保障人權最佳的政府限縮門診你知道台大你們台大健康政策管理研究所門診的數量真的不用太重我現在不跟你說了我現在不請你講你之前在這裡說的黃正熙教授有要替我看其實大家都看了沒有啦我現在沒有在提你台港主席我要問問題他這樣子一直台港我怎麼問"},{"start":1257.856,"end":1270.499,"text":"我是說台大健康政策管理研究所的副教授郭年珍他最近也撰文指出個別醫院總額上路會遇到的四個問題第一個限縮門診手術是否會影響就醫的限縮門診和手術會不會影響到就醫的可進性"},{"start":1278.041,"end":1295.737,"text":"那第二個就是說啊如何避免醫療醫院選擇輕症病患啊如何避免啊今年醫院的總額比去年增加了370億欸那預期的點值穩定性會提升啊可是關鍵問題在如果避免影響民眾就醫的可進性和醫療品質很低啊但是有可能"},{"start":1303.781,"end":1323.394,"text":"醫院我們健保多給了370億然後你們漲部分負擔也增加了醫院的收入然後呢如果再增加掛號費收入又要增加可是未來掛號掛不到然後檢查檢查不到然後未來看病的可靜性會受影響"},{"start":1324.855,"end":1353.422,"text":"你有沒有可能面臨導致高醫療需求的病患不符但是不符合重症的範圍面臨更大的困難或者是變成全民搶掛號大賽大家都要搶掛號都拜託你不要搶掛號或是促使醫院策略性的選擇輕症病患平轉或上轉醫療資源耗用多的病患給其他公立的醫院進一步的加劇醫療資源分配不均"},{"start":1355.37,"end":1380.423,"text":"然後再來第三點 郭年增教授講的醫院內部資源分配和管理衝突這不是醫病的問題 也不是醫院跟病人的問題而已光是醫院內部各分科的內部資源分配和管理就會產生衝突所以在某些科別好看的 成本低的 然後服務量增加"},{"start":1381.443,"end":1394.166,"text":"然後薪資裡面呢 如果這種像成本高的不賺錢的科別 然後人數下降這邊看這個吃力不討好的 醫生會收入減成本高的 成本低的 然後好看的 人看越多越賺錢的 醫生薪水越來越高"},{"start":1402.228,"end":1430.404,"text":"光是在這種狀況裡面醫師現有的薪酬制度除了兼行政主管或擔任研究醫師以外仍然都是以不拖你服務的量能為基礎鼓勵多做來分配酬勞和所得可是你當總額受到嚴格的控制然後醫院如果沒有有效的調整薪資激勵這個這個激勵的鼓勵的機制的話你如果反向的鼓勵不要充量然後你沒有鼓勵"},{"start":1431.405,"end":1432.286,"text":"你這個管理食物上還有一種問題是論人記仇的狀況那你減少醫療你要讓這個醫生和部門之間真的啦這問題很嚴重的譬如說"},{"start":1450.475,"end":1470.796,"text":"本醫來得住院 住院的我們都知道門診轉住院的病患病情比較穩定住院的天數容易管理比較有機會接受自費治療可是急重症的急診他轉住院的病患病情是相對嚴重的住院的時間也不確定的"},{"start":1472.498,"end":1477.764,"text":"也可能比較容易被排擠有沒有可能在醫院的管理上他們在各部門的住院收留上寧可優先選擇收留門診轉上來的"},{"start":1487.435,"end":1499.205,"text":"而策略性的將急重症的急診部門的要轉病房的讓他留在急診室導致急診有壓力進一步升高因為這部門和部門之間 我也要選定他要選勤課 他也要選籌檔的"},{"start":1507.173,"end":1536.029,"text":"所以在這種狀況裡面這一類的急診和非急診專科的衝突在醫院裡面會不會被進一步的放大畢竟多收一個急診的患者即使能有健保的加成或是排除個別的總額之外相較於門診排成的住院病患哪一個比較符合他們那個部門的利益這個是很現實的因為那個部門也有護理人力缺護理師也考量到我寧可照顧"},{"start":1536.869,"end":1540.212,"text":"門診轉上來誰要照顧那個急症急重症轉上來的所以為了在這種狀況裡面這個問題都是內部管理會衝突的而犧牲的是病人啦在這種狀況裡面還有一種病床控管的方式並不是由科部統一管理有一些醫院的病床的管理是根據個別醫師資歷去分配的"},{"start":1563.717,"end":1579.807,"text":"而個別醫師的資歷的分配中它導致有空床仍然無法有效收治急診的病患所以在這裡我並不是說我們反對你分級醫療並不是說你反對你個別醫院的總額管制而是"},{"start":1581.257,"end":1596.305,"text":"你要做的你要監測的更細緻你的配套機制要更完善而是你要預期到可能的衝擊對病人的衝擊是什麼而你的因應之道是什麼請問我剛剛講那些問題你們的配套是什麼"},{"start":1601.547,"end":1615.238,"text":"病人受到這麼大的衝擊 你的配套是什麼所以在醫界 在學界人家已經跟你講你的政府要細緻的進行相關的監測和配套機制你講話怎麼這樣你們現在有什麼細緻的監測和配套機制你們監測的項目有哪些監測的頻率會如何設定監測後的檢討設定多久時間"},{"start":1627.984,"end":1643.915,"text":"包園,你剛剛提的,不管是郭教授,或者是你提的寶貴的見解其實我們都知道我現在問你,你也在這裡,不是問你知不知道,我問你啊你現在監測的配套機制是什麼,你若不能說,叫你書長來說啦我看你是不會說啦,叫你書長來說你,謝謝記者,讓書長我問一下"},{"start":1654.679,"end":1666.489,"text":"醫療可見性和品質的衝擊跟委員報告這個個別醫院總額除了台北區之外全部都在今年1月1號都實施了台北區當然是最困難的"},{"start":1668.371,"end":1673.493,"text":"南區高屏區東區都已經早已實施多年所以這個不是一個新的制度因為這些問題在過去實施之前也都有這樣的疑慮但是實施下去之後我們各區的你不要這樣子好不好中南部的醫療現場的問題跟我們北區會一樣嗎"},{"start":1692.76,"end":1704.732,"text":"一個大台北地區多少人你知道嗎大台北就好了北北基就好了多少人你告訴我700萬人啊但是大台北地區啊700萬在全台灣三分之一耶北北基而已耶"},{"start":1709.929,"end":1737.723,"text":"你知道2004年就以醫院卓越計畫之名推行過了類似個別總額的制度了啦這個概念在2004年就做過了那因為部分醫院減少開立藥品種類和數量而且限制門診量導致民眾申訴掛不上號醫院減少開藥種類或數量甚至有醫學中心因為頻繁遭投訴而被中區健保業務組終止合約但是因為當時是自願參與的"},{"start":1739.884,"end":1766.143,"text":"而未參加的醫院這個點子會讓他下降然後影響了整體醫療生態最後這一個計畫被監察院糾正欸那我不認為現在的計畫跟當時是一模一樣但是你們面對這個的態度你們認為台北的模式跟中南部會一樣都不會有問題學者專家叫你們監測什麼你們要監測了嗎"},{"start":1769.105,"end":1775.87,"text":"有監測嗎 都會參考啦他們叫你監測什麼 你先回答我你先回答我 他們要求的監測合不合理他們要求監測什麼東西 你回答得出來嗎"},{"start":1786.277,"end":1814.966,"text":"我們有很多的指標在檢測他在說你們都知道知道 你連聽都不想聽人家建議 監測實施前後的實施前後的門診和住院病患的屬性變化監測病人就醫流向是不是出現不合理的平轉或下轉引導醫院建立更合理的薪酬和資源分配機制"},{"start":1816.363,"end":1824.93,"text":"引導醫院建立更合理的星球和資源分配機制你們的對策是什麼你們的手段 蘿蔔和棒子是什麼"},{"start":1829.793,"end":1849.01,"text":"大家都轉到台大和北龍然後像那個人酬的話不收的話是要轉出那邊處分還是還是台大和北龍要負責我真的要語重心長的跟委員報告啦您的資料我們都會我們都了解也會解決但是我不是要來了解我現在問你說人家拋出來的問題"},{"start":1851.932,"end":1872.364,"text":"他們絕對都是...我是幫醫院拋出來的問題拿來問你我不是在問醫院院長我擔心的是衛福部部長你要怎麼解決而你講不出來所以我擔心啦有蘿蔔有棍子但是不是一個學者所講的就代表全部"},{"start":1873.044,"end":1878.666,"text":"我現在最好說一句啦現在我最好說一句啦 因為我說很久了啦你為大家不是靠上身就可以解決問題你不是大家叫你為上身就可以解決問題今天在這裡是說 人家提出問題了你有什麼看法 你有什麼解方你面對病人受到這麼大的衝擊 你的配套是什麼而今天"},{"start":1901.713,"end":1923.559,"text":"而今天整個衛福部包括部長包括署長都對我們提出來的病人受到衝擊回答不出來不願意回答然後轉移焦點答非所問這才是大問題啦我們會解決所有的您擔心的問題大家宣誓性的唯獨一再的宣誓而已謝謝"}]}}},"gazette":{"lineno":887,"blocks":[["林委員淑芬：（12時7分）謝謝主席，請邱部長。"],["主席：請邱部長。"],["邱部長泰源：委員好。"],["林委員淑芬：部長好。今天大家談了很多急診壅塞和護理人力的問題，但我還是要繼續講。大家都在談病房護病比的限制、護理人力的不足，導致醫院關病房、急診住院待床病人滯留狀況加劇，上次我也就教於你，光是檢傷第一級的平均留置時間都超過標準時間的8小時，還要到雙倍以上啦！我現在就請你看一個圖，到底你對於媒體報導護理人力「平均年齡39歲，資深護理師留任見效」，你們自己是這樣講：「留任見效」，你是怎麼看待這個資訊的？"],["邱部長泰源：我是不是請司長先回答一下？"],["林委員淑芬：啊？我說叫你看，它就是這樣講。你們自己發布的新聞，你自己都沒看過嗎？就是說2024……"],["邱部長泰源：林委員，因為這時候我還沒上任，所以我要仔細看一下。"],["林委員淑芬：不是啊！這是前幾天……去年5月13日的新聞，你還沒上任？好，那你知道這個議題，也應該了解一下吧！"],["邱部長泰源：我當然希望護理資深人員能夠留任啊！"],["林委員淑芬：不是啦！從早上大家一路問你，你都覺得離職的雖然很多，但你們的12項政策是要求穩定，而且已經見效，人力其實都是增加的；雖然有離職的，但是你們司長剛才也一直講人力普遍上還是增加的，從你們的職等統計都看得出來。那麼照你們現在看出來的數據，我告訴你，2021年護理師執業的平均年齡是36.95歲，2024年是39.25歲，那我這樣問你就好了、就這件事情啦！執業的平均年齡愈來愈增加，你怎麼看待這一件事情？平均執業年齡提高啊！你怎麼看啦！"],["邱部長泰源：這可能要從兩個角度嘛！如果……"],["林委員淑芬：因為當初、去年你們認為、肯定這是……"],["邱部長泰源：如果能夠把資深的留下來，從這個角度來看，也許是好事情啦！那是不是說年輕的留不住？也是一件事情啦！這個可能要看……"],["林委員淑芬：但我們也很好奇啊！為什麼年輕的留不住？因為我們開設了多元的人才、人力培養啊！包括學士後護理系持續地開設，而且包括護理師考試從一年2次變成一年3次，但平均執業年齡卻節節攀升，你也講了，留不住年輕的、專業的護理人力。部長，你知道嗎？2012年臺灣護理人員的平均執業年齡是幾歲嗎？2012年啦！你猜猜看，你用猜的。你們那邊沒有數據啦！你用猜的，你猜猜看。"],["邱部長泰源：有啦！你剛剛有秀一下啦！"],["林委員淑芬：好，那是多少歲？被你偷看到了。"],["邱部長泰源：29.6歲嘛！"],["林委員淑芬：2012年29.6歲，2024年39.25歲。當時2012年離現在並沒有很久！你們的專案報告是說平均年齡29歲，而且21到30歲族群最多，占了43.6%，43.6%都是30歲以下的護理人力，而現在30歲以下護理人力可能是低得不像樣。對於這些數字，其實你都沒有掌握，我剛剛問你，你也搞不清楚。到底我們要肯定平均年齡39歲是留任成功，還是我們要擔心？2012年平均年齡是29歲，2024年平均是39歲，如果照這個邏輯，到2036年，平均執業年齡會不會變成49歲？有沒有可能是這樣子？39歲都還留任成功，我們很感謝這些資深的護理師扛起了這個責任，可是呢？我們……"],["邱部長泰源：我們擔心的當然是年輕族群沒有進來啦！"],["林委員淑芬：年輕的族群沒進來，可是我們的養成班開很多啊！我們現在問的是剛剛已經有委員講的，到澳洲年薪170萬元、到美國300萬元起跳，但都還要扣掉生活費，如果在這裡的待遇和工時能夠改善的話，大家都知道，如果可以留在自己的家鄉，誰願意遠離故鄉呢？"],["邱部長泰源：了解，是、是、是。"],["林委員淑芬：不是「了解」而已啊！"],["邱部長泰源：我們會朝這方面來努力。"],["林委員淑芬：你們開源人數理論上是增加的，取得證照的人數也愈來愈多，可是平均執業年齡卻愈來愈高，這是不合理的，在這種狀況裡面，畢業生不來、新血留不住、資深扛起來。然後病房關床、急診壅塞，一環扣一環。這些畢業生流到外國去，難道臺灣是要變成國際護理師的職訓中心嗎？臺灣護理人才的養成，是要幫國際護理人員變成後備養成中心嗎？"],["邱部長泰源：我們很希望我們培養出來的都能夠留在國內，因為國內還是需要這些人才。我們會想盡辦法把他們留在國內。"],["林委員淑芬：對啊！所以我們現在是政策規劃有問題、政策規劃不力，還是執行面有問題？在這種狀況裡面，不要動不動就覺得……司長剛剛講，我們的人數是增加的，但人數增加的都是資深的，年輕的、優秀的，沒有新血進來，所以你的KPI應該是護理人員回流多少、病床開床率是多少，而不是在這裡說有增加，結果病床關得愈多、急診愈壅塞。","現在也有護理人員講啊！如果是醫生或醫院跟你們反映問題，你們都馬上回應、有所回應，但護理人力跟你們反映問題、護理工會跟你們反映問題，你們毫無感覺，護理人員只好用集體離職來跟你們做無聲的抗議。現在人家反映了，你們面對護理人員和對醫師或對醫院時，他們講話的分量不一樣啊！分量不一樣，只好用離職來告訴你他抗議。這是大問題！部長，要怎麼做？要怎麼做？你的12項政策工具現在好像也是留住資深的而已，資深的而已！"],["邱部長泰源：我們很希望……因為一進來工作是不是滿意，對新手啦！對新手其實是非常重要的，所以我們有護理新手的臨床導師把他帶起來，因為……"],["林委員淑芬：好啦！我希望半年後你來告訴我，你的12項政策讓年輕護理師願意留下來為臺灣的病患服務啦！"],["邱部長泰源：好，我們全力以赴。"],["林委員淑芬：半年後我會再問你喔！就不要再講……半年前我問你醫院有公安危機的，你還沒告訴我、還沒回答我喔！","但我今天還有更重要的要問你，除了這個問題以外，還有今年實施的醫院個別總額制問題，在第二季要上路了，針對醫院個別總額制的問題，你們有一個很有效的打擊醫療人球策略和方案，你有很有效的蘿蔔和棒子。你知道健保總額增加了七百多億元，醫院增加了三百多億元吧？至少醫院拿走了一半以上吧！醫院多拿了幾百億元的錢出來，卻這樣急診壅塞、關病床，這已經夠荒謬、夠好笑了，我今年要給你三、四百億元，結果關的病床更多、結果急診更壅塞，然後你說你有醫療人球的應對策略。那我現在問你，你有沒有盤點到未來在醫院個別總額制下，醫療現場會面臨哪一些衝擊？你又有什麼因應策略？"],["邱部長泰源：我可不可以分兩段來報告一下？"],["林委員淑芬：好。"],["邱部長泰源：因為我們今年所有的預算都還沒有settle down，所以還沒能夠開始落實，各種不管是醫院、基層相關，連護病比的獎金現在都還沒有開始發啦！我希望預算的會計進度能夠趕快走完……"],["林委員淑芬：你現在是在講什麼？我在講個別醫院總額制。"],["邱部長泰源：第二，關於個別醫院總額，我們當然知道個別醫院總額是這樣，在臺北區也是第二季才會開始……"],["林委員淑芬：對啊！個別醫院總額也是第二季才要開始啊！"],["邱部長泰源：臺北區現在所發生的醫院壅塞問題當然……應該是還沒有跟個別醫院總額這個問題……"],["林委員淑芬：我沒有在問你這個，我現在問你的是……"],["邱部長泰源：個別醫院總額的話，我們當然不能讓它有人球發生。"],["林委員淑芬：你這樣實施個別醫院總額制，實行下去以後，醫療現場會發生什麼樣的變化？看病的民眾會受到什麼衝擊？我現在是在問這個啊！"],["邱部長泰源：了解。"],["林委員淑芬：我是站在病人和人民的立場問這個啊！"],["邱部長泰源：我想，這個也不是突然要去做啦！"],["林委員淑芬：不是啦！會有什麼衝擊你怎麼講不出來？沒關係，我沒有管你是不是突然……"],["邱部長泰源：因為南區在這部分就做得很好。"],["林委員淑芬：而且我也不見得認為這樣是錯的、我不認為這樣就一定是不行的，但我現在的問題是有可能面臨到、看病的人可能受到的衝擊是什麼？你來告訴我。因為你告訴我了，才代表你會想你的因應策略是什麼，那就證明你每一個新政策的施行都有評估、有步驟，而且面對最後的衝擊，你們也有因應的策略，我是要看到這個過程啊！所以我現在問你，推這樣的新制度上路，你有沒有盤點過醫療現場會面臨什麼衝擊？"],["邱部長泰源：好……"],["林委員淑芬：第一個是什麼？"],["邱部長泰源：我想，醫院在財務上的自我管理會更加謹慎，對病人就會用最有效益的方式解決……"],["林委員淑芬：你可不可以講具體一點啊？不然我講給你聽，你是部長耶！不然我講給你聽啦！"],["邱部長泰源：我再舉個例子，住院的日子就會……"],["林委員淑芬：好啦！第一，聽了你講這個，我認為你不食人間煙火，因為很多醫院都跳出來反映了、很多醫院的發言人都出來講話了。第一，根據媒體的報導，民眾最擔心的就是醫學中心的掛號費會不會調漲。臺大醫院目前掛號費100元、健保部分負擔420元，發言人就表示，各種醫療支出、藥價不斷攀升，去年點值不到0.9，仍然遠遠趕不上高漲的電費、人事費。為了因應可能的財務衝擊，他們已經商量很多了，不排除最後一刻就是調漲掛號費。然後，新光醫院的副院長、大家都知道的醫務管理學會理事長洪子仁也表示，不過！他們講得更多喔！他們盤點醫院量能，能做的調控措施包括調高掛號費，此外，有減少周六及夜間門診、控制掛號人數、延後非緊急手術等等。","現在事情嚴重嗎？我現在說這些，代表可能的衝擊在這裡。生病的人會受到的衝擊，如果是花錢可以解決的，還算是最小的，像是調高掛號費；再來是花錢也無法解決的：周末假日、夜間門診減少了，就是花錢要掛號也掛不到的。控制掛號人數，要掛也掛不到，半夜、周末的，對急重症的病人延後非緊急手術，那意思就是都不要生病啦！要是病情不上不下的，急重症當然排除在外面啦！但是還有一種是檢傷輕的報成重的，這也不無可能啊！在這種狀況下，調漲掛號費還掛不到號，民怨四起啊！對民眾來講可能衝擊到醫療品質，包括掛號、看診更困難，自費項目變多、手術被延後。消基會董事吳榮達擔憂，這一個新制上路後，醫療品質會下降，醫院如果縮門診量，民眾掛號、看診更困難，會影響就醫的可近性。當然，我們希望分級醫療，所以縮門診量是對是錯，我們姑且不論，但是這位消基會董事也講，檢驗、檢查、手術時間的遞延也會影響病情的發現，導致病情惡化。如果醫院自行限縮醫療服務的申報、門診、檢查、檢驗、手術、住院減少，事情就來了喔！可能會影響醫療人員的收入，加劇人力的出走，這點你們想過嗎？","你可知道？不是我們不支持分級醫療，有時候到小診所，醫生檢查不出問題，都會叫我們為了慎重起見，到醫學中心去做檢查啊！有沒有這種狀況？有啊！很多啊！還有一個，根據媒體報導，56歲的楊女士服用高血壓藥6年，都在臺中榮總心臟內科定期回診、拿單。她不懂什麼是總額，為了掛號，她覺得就算掛號費漲，她也會吞下去。但是她曾經因為服用醫院給的藥，不要忘了你們還有缺藥問題喔！缺藥的問題，尤其是一些特殊的藥，只供給給醫院，沒有供給給地區醫院、沒有供給給地方診所，也沒有供給給地區藥房。她說她的經驗是當她病情穩定了，醫院將她下轉到診所，但診所藥物從原廠藥變成學名藥，還需要在醫學中心回診，以及每半年都抽血檢驗。一下子在診所，檢驗又要回到醫學中心就算了！後來有時候檢查發現變嚴重了，又要到中榮就診。","我現在要講的是：分級是對的，但是有很多狀況並不是民眾迷信醫學中心或教學醫院，而是事情的演變就是這樣，吃藥吃得好好的、控制得好好的，醫院叫她去診所卻控制得不好，她就必須再回醫學中心。所以這是很複雜的！不一定大家都喜歡逛醫院，也不一定大家都認為到醫學中心好，可是她的經驗就是如此，所以她覺得這種狀況怎麼處理呢？你不可以僅憑政策調整，或者是從上面講說就是這樣沒問題，可以改變的。你要掌握民眾的就醫習慣和決策行為，這是很複雜的，單純調高掛號費也不代表能夠有效地降低民眾因輕症前往醫學中心就診的狀況。這個我也質詢過，你調整了部分負擔，結果呢？到醫學中心裡面看病、看門診的量增加再增加！現在只改變什麼？從人民的荷包掏出更多錢這件事情而已，你想做的分級醫療沒有改變！你當初漲部分負擔時就說是為了落實分級醫療，結果沒有辦法控制啊！無效啊！無效的政策啊！那現在呢？醫改會也擔心啦！門診減量以後，醫院可能會透過健保轉自費減少慢性處方箋的釋出、調漲掛號費來增加收入，導致病人看病變貴。為了讓治療項目得到保障，甚至可能將輕症報為重症。為了避免過度申報而斷頭給付，也可能會發展什麼？如果因為報太多被斷頭給付，那醫院要怎麼因應啊？如果你是醫院經營者，你要怎麼因應，部長？"],["邱部長泰源：真的很敬佩委員喔！對醫療體系這麼……"],["林委員淑芬：不要啦！不要敬佩，你告訴我啦！上有政策、下有對策，你覺得醫院會怎麼因應啊？"],["邱部長泰源：所以你剛剛講得很好，它是基於非常複雜的因素。但是我必須跟大家講，今天我們生活在臺灣這個國度是非常幸福的……"],["林委員淑芬：我現在要跟你講你的政策有沒有問題啦！我在提醒你政策可能的問題在哪裡。"],["邱部長泰源：我要先講，我們用全世界算比較低廉的醫療費用就得到世界最好的醫療品質，所以一定要改革嘛！"],["林委員淑芬：你講不出來，我就告訴你啦！醫院面對病人一直去看病、一直去看病，沒有辦法拒絕病人，就有可能……"],["邱部長泰源：我們一定要改革，讓健保永續……"],["林委員淑芬：請你閉嘴一下好不好？部長，我沒有問你。"],["邱部長泰源：讓人民永遠得到好的照顧。"],["林委員淑芬：現在時間不算喔！我沒叫你回答，你只是一直跟我爭辯。我要跟你講，醫院要面對這麼多人來看診，它怎麼因應？上有政策、下有對策，道高一尺、魔高一丈啦！醫院會透過門前診所啦！將輕症帶出醫院治療啦！而門前診所已經很多了、很普遍啦！"],["邱部長泰源：這個就是我們在稽核的重點之一。"],["林委員淑芬：哎呀！當稽核的重點之一，有改變嗎？有解決嗎？"],["邱部長泰源：有啊！我們各區的管理在這個部分是特別重視。"],["林委員淑芬：沒有啦！將輕症帶出醫院，假裝不是醫院去看的，而是門前診所，然後再去瓜分西醫基層診所的總額、從醫院的總額再瓜分診所的總額。而中重症的病人如果沒人要收，統統送到公立醫院，讓公立醫院的護理人力更荒。所以，如何避免醫院選病人，因應衝擊的配套在哪裡？如何讓人家……對於我剛剛提出來的可能問題，你們是有能力因應的嗎？你來告訴我，透過健保轉自費，你要怎麼處理？減少慢性箋的釋出，你要怎麼處理？調漲掛號費，但是沒有改善醫療分級的問題，你怎麼處理？針對門前診所，你說你要列為評鑑的項目，但是沒有效，那你要怎麼處理？"],["邱部長泰源：委員所擔心、所提出的，請你放心，我們一定一個一個把它監測、克服，保障人民最大的幸福。"],["林委員淑芬：還有、還有！問題不是只有這樣而已，包括限縮門診！你知道你們臺大健康政策與管理研究所……"],["邱部長泰源：門診數量真的不能太重，一個醫師看一百多人……"],["林委員淑芬：我還沒請你答復，請你慢點說。"],["邱部長泰源：只有王正旭教授看看有沒有那個體力可以看診啦！其實大家都看得很辛苦，如果可以不用……"],["林委員淑芬：我現在不是在和你抬槓。主席！我要問問題，他這樣子一直抬槓，我怎麼問？"],["邱部長泰源：沒有啦！我是回答……"],["林委員淑芬：我是說臺大健康政策與管理研究所副教授郭年真最近也撰文指出個別醫院總額上路會遇到的四個問題，第一個是限縮門診和手術會不會影響到就醫的可近性；第二個是如何避免醫院選擇輕症病患。今年醫院的總額比去年增加了370億元，預期的點值穩定性會提升，可是關鍵問題在於如何避免影響民眾就醫的可近性和醫療品質，錢多了啊，我們健保多給了醫院370億，你們漲部分負擔也增加了醫院的收入，然後如果再增加掛號費，收入又要增加，可是未來有可能掛號掛不到、檢查也檢查不到，然後看病的可近性會受影響，有沒有可能導致有高醫療需求但是不符合重症範圍的病患面臨更大的困難？或者是變成全民搶掛號大賽，大家都要搶掛號，都拜託立委搶掛號，或是促使醫院策略性的選擇輕症病患，平轉或上轉醫療資源耗用多的病患給其他公立的醫院，進一步的加劇醫療資源分配不均？第三個是醫院內部資源分配和管理衝突的問題，這不是醫病的問題，也不是醫院跟病人的問題而已，光是醫院內部各分科的內部資源分配和管理就會產生衝突，所以某些好看的、成本低的科別服務量增加，在新制裡，成本高的、不賺錢的科別人數下降，這邊這個吃力不討好的醫生會收入減少，而成本低的、好看的科別的看診人數愈來愈多更賺錢，醫生薪水愈來愈高，光是在這種狀況裡面，醫師現有的薪酬制度，除了兼行政主管或擔任研究醫師以外，仍然都是以不脫服務量能為基礎，鼓勵多做來分配酬勞和所得，可是當總額受到嚴格的控制時，醫院如果沒有有效的調整薪資，有激勵、鼓勵機制，如何反向的鼓勵不要衝量？","管理實務上還有一種問題是論人計酬的狀況，你減少醫療，要讓醫生和部門與部門之間，真的啦！這個問題很嚴重耶！譬如說醫院裡的住院病患，我們都知道門診轉住院的病患病情比較穩定，住院的天數容易管理，比較有機會接受自費治療，而急重症的急診轉住院病患的病情是相對嚴重的，住院的時間也不確定，也可能比較容易被排擠，有沒有可能在醫院的管理上、在各部門的住院收留上，寧可優先選擇收留門診轉上來的而策略性的將急重症的急診部門要轉病房的病患留在急診室，導致急診壅塞，壓力進一步升高？因為部門和部門之間也要選擇啊！當然要選輕鬆的哪會選粗重的？在這種狀況下，這一類的急診和非急診專科的衝突，在醫院裡面會不會被進一步的放大？畢竟多收一個急診的患者，即使能有健保的加成或是排除於個別總額之外，相較於門診排程的住院病患，哪一個比較符合他們那個部門的利益，這個是很現實的，因為那個部門也有護理人力缺口，護理師也會考量寧可照顧門診轉上來的，誰要照顧那個急診急重症轉上來的？這些都是內部管理會有衝突的問題，而犧牲的是病人啦！","在這種狀況裡面還有一種是病床控管方式問題，並不是由科部統一管理，有一些醫院病床的管理是根據個別醫師資歷去分配的，這個依據個別醫師資歷分配的狀況導致有空床仍然無法有效收治急診病患，在這裡我並不是說我們反對你們的分級醫療，並不是反對個別醫院的總額管制，而是說你要做得、你要監測得更細緻，你的配套機制要更完善，是你要預期到可能對病人的衝擊是什麼，要知道你的因應之道是什麼。請問對我剛剛講的那些問題，你們的配套是什麼？病人受到這麼大的衝擊，你的配套是什麼？醫界、學界已經跟你講，政府要細緻的進行相關的監測和配套機制，你說說看，你們現在有什麼細緻的監測和配套機制？你們監測的項目有哪些？監測的頻率會如何設定？監測後的檢討設定多久時間？"],["邱部長泰源：報告委員，你剛剛提的不管是郭教授或者是你的寶貴的見解，其實我們都知道，我們都很清楚，而且我們當然有配套啊！比如說……"],["林委員淑芬：立委在這裡不是問你知不知道，我問你啊！你現在監測的配套機制是什麼，你如果不會講，叫你們署長來講啦！我看你是不會講，叫你們署長來講啦！"],["邱部長泰源：感謝委員有機會讓署長發揮一下。"],["林委員淑芬：署長來就對醫療可近性和品質的衝擊說一下。"],["石署長崇良：跟委員報告，這個個別醫院總額，除了臺北區之外，全部都在今年1月1號實施了。"],["林委員淑芬：臺北區當然是最困難的。"],["石署長崇良：北區、南區、高屏區、東區都早已實施多年，這個不是一個新的制度……"],["林委員淑芬：我現在問的是剛才大家討論提出來的問題、衝擊，你要如何因應。"],["石署長崇良：您的這些問題在過去實施之前也都有這樣的疑慮，但是實施下去之後，我們各區的……"],["林委員淑芬：你不要這樣子好不好？中南部的醫療現場的問題跟我們北區會一樣嗎？一個大臺北地區有多少人，你知道嗎？北北基就好了，北北基有多少人？你告訴我。"],["石署長崇良：700萬人。"],["林委員淑芬：對呀！700萬人，占全臺灣三分之一耶！這還是北北基而已。"],["石署長崇良：但是大臺北地區的醫療資源更為豐盛。"],["林委員淑芬：你知道2004年就以醫院卓越計畫之名推行過類似個別總額的制度了，這個概念在2004年就做過了，因為部分醫院減少開立藥品種類和數量而且限制門診量，導致民眾申訴掛不上號、醫院減少開藥種類或數量，甚至有醫學中心因為頻繁遭投訴而被中區健保業務組中止合約，但是當時是自願參與的，而未參加醫院的點值會下降，然後影響了整體醫療生態，最後是這個計畫被監察院糾正，我不認為現在的計畫跟當時是一模一樣的，但是你們面對這個的態度，你們認為臺北的模式跟中南部會一樣，都不會有問題，學者專家叫你們監測什麼，你們要監測了嗎？有監測嗎？"],["石署長崇良：都會參考啦！"],["林委員淑芬：他們叫你監測什麼？你先回答我。"],["石署長崇良：如果以現在來看……"],["林委員淑芬：你先回答我。"],["石署長崇良：沒有實施的臺北區壅塞，已實施的其他區沒有壅塞……"],["林委員淑芬：你先回答我，他們要求的監測合不合理？他們要求監測什麼東西，你回答得出來嗎？"],["石署長崇良：我們有很多的指標在監測……"],["林委員淑芬：他們在說什麼你們連聽都不聽了，還在說你們都知道，知道？你連聽都不想聽！人家建議監測實施前後的……"],["邱部長泰源：郭教授的意見我們研讀了半天，都在做啦！"],["林委員淑芬：實施前後的門診和住院病患的屬性變化，監測病人就醫流向是不是出現不合理的平轉或下轉……"],["主席：林委員，請石署長到你辦公室報告啦！"],["林委員淑芬：引導醫院建立更合理的薪酬和資源分配機制，你們的對策是什麼？你們的手段──蘿蔔和棒子是什麼？大家都轉到臺大和北榮？然後像那個人球，不收的話是要轉出那邊受處分，還是臺大和北榮要負責？"],["邱部長泰源：我真的要語重心長的跟委員報告，您的資料我們都瞭解也會解決……"],["林委員淑芬：我不是要你們瞭解，我是問你們說人家拋出來的問題……"],["邱部長泰源：但是請你要相信各醫院的院長，他們絕對都是悲天憫人，以人民為重，所以不用擔心。"],["林委員淑芬：我是幫醫院把拋出來的問題拿來問你，我不是在問醫院院長，我擔心的是衛福部部長你要怎麼解決，而你講不出來！所以我才擔心哪！"],["邱部長泰源：我們將來有蘿蔔、有棍子，但是不是一個學者講的就代表全部，你要相信醫療人員絕對是站在人民健康的立場。"],["林委員淑芬：我最後說一句，立委站在這裡不是靠相信就可以解決問題，你也不是在這裡靠著要立委相信就可以解決問題，今天在這裡講的是人家提出問題了，你有什麼看法、有什麼解方？面對病人受到這麼大的衝擊，你的配套是什麼？"],["邱部長泰源：所有提出的問題我們一定會蒐集。"],["林委員淑芬：而今天整個衛福部，包括部長、包括署長都對我們提出來的病人受到的衝擊回答不出來，不願意回答，然後轉移焦點、答非所問，這才是大問題。"],["邱部長泰源：我們會解決所有您擔心的問題。"],["林委員淑芬：這種宣示性的話也只是一再的宣示而已。"],["邱部長泰源：謝謝。"],["主席：謝謝林淑芬委員，謝謝部長。","我們請羅智強委員發言。"]],"agenda":{"page_end":314,"meet_id":"委員會-11-3-26-2","speakers":["蘇清泉","陳昭姿","林月琴","陳菁徽","王育敏","邱鎮軍","廖偉翔","涂權吉","黃秀芳","王正旭","林淑芬","羅智強","黃國昌","楊瓊瓔","陳瑩","洪孟楷","張啓楷","劉建國","陳培瑜","楊曜","王義川"],"page_start":227,"meetingDate":["2025-03-13"],"gazette_id":"1142701","agenda_lcidc_ids":["1142701_00006"],"meet_name":"立法院第11屆第3會期社會福利及衛生環境委員會第2次全體委員會議紀錄","content":"邀請衛生福利部部長就「有關全國急重症醫療量能」進行專題報告，並備質詢","agenda_id":"1142701_00005"}}}