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    Title: 決策的社會鑲嵌性及其影響：台灣中醫及牙醫健保總額支付委員會決策機制之分析
    The social embeddedness of the decision-making and its influence: The analysis of the decision-making mechanisms in the Chinese medical and dental global budget payment committees in Taiwan
    Authors: 王光旭
    Wang, Guang Xu
    Contributors: 陳敦源
    Chen, Don Yun
    王光旭
    Wang, Guang Xu
    Keywords: 網絡
    鑲嵌
    決策
    社會網絡分析
    健保總額
    總額支付委員會
    network
    embeddedness
    decision-making
    social network analysis
    the NHI global budget payment system
    Committee of the Global Budget Payment System
    Date: 2009
    Issue Date: 2010-04-09 17:08:28 (UTC+8)
    Abstract: 本研究的焦點主要圍繞在兩大主軸：社會鑲嵌性與決策，探討在行動者間社會網絡的關係結構下，決策的影響力與決策行為的社會性。換言之，本研究認為決策並非僅是理性的產物，更多的時候，反而是理性與非理性因素交互作用的結果。也就是說，決策必然鑲嵌在決策者間的社會網絡關係結構，任何的決策都無可避免的必須考量到決策者間的關係型態所造成的限制。本研究使用牙醫與中醫總額支付委員會作為研究的個案，除了讓社會網絡與決策網絡的邊界更清楚，更符合研究校度之外，也希望能夠進一步透過兩個案的分析，一方面透過社會網絡分析瞭解兩支付委員會可能的權力分佈與結構，二方面分析影響決策權力分佈與決策產出的關係機制為何，並藉此來驗證決策的社會鑲嵌性此一概念。

    本研究使用事務討論、信任支持、法規諮詢與資源交換四個社會關係網絡來測量行動者在決策過程中的社會關係，並用以驗證決策者的決策影響力與決策的一致性是否鑲嵌在這四個網絡的結構當中。本研究透過社會網絡的問卷蒐集了牙醫支委會18筆與中醫支委會21筆資料（N=56），並透量化社會網絡分析方法中的集中性指數、派系、網絡密度、區截模型與縮影矩陣、MDS分析與QAP的相關與迴歸分析等分析工具，從個體、小團體層次、與總體的結構層次，分析牙醫與中醫支委會的行動者在網絡中的關係型態與位置角色。此外，更透過上述分析中所獲得的集中性指數的分析結果當作自變項，並放入迴歸模型之中，藉以驗證是否對集體決策產出的觀感造成影響。

    總的來說，本研究可歸納以下研究結論：一、在牙醫與中醫支付委員會的個案中，委員決策的影響力與決策行為，確實都受到四個社會網絡結構的影響，驗證了決策的社會鑲嵌性此一觀點；二、無論從個體、小團體或總體結構的分析層次，得到的分析結果都很類似，具有決策影響力並與其他行動者有密切的社會關係的行動者，在牙醫支委會有牙醫全聯會的H11, H16與健保局的A2，但中醫支委會的部分，就沒有健保局的代表，反而僅有中醫全聯會代表，顯見在牙醫部門當中，權力的分佈屬於公、私部門間二元的機制，但中醫的部分僅有集中在中區中醫師；三、委員的出席確實會受到委員個人政策影響力與資源交換網絡的顯著影響，顯示個人政策影響力愈大，與其他委員資源交換關係愈頻繁的委員，參與會議的意願較高；四、從影響集體決策產出觀感的因素來說，事務討論關係與在事務討論網絡的派系重疊程度對集體決策產出的觀感有顯著且正面的影響，個人的決策影響力與年資反而有負面且顯著的影響。

    本研究大的貢獻，一驗證了決策的社會鑲嵌性此一觀點，決策必須將社會關係變項考量，二是在公共行政領域中第一本以系統化的方式使用社會網絡分析工具的論文，非但具有示範性的作用，也跨越了過去公共行政網絡研究過於喻象的分析缺陷。根據分析結果，本研究提出以下四點政策建議：一、中醫支委會的健保局代表應當夠積極的與中醫全聯會的代表建立溝通的關係，以構築決策影響力的社會基礎；二、委員會中若不具決策影響力，又在社會關係上沒有跟其他行動者互動，則應考慮其存在的實質意義；三、由於年資長短對決策觀感會有負面影響，健保局應更積極的與年資較久的委員溝通請益，瞭解他們為何會對委員會的運作績效有負面的想法，藉以強化委員會的功能；四、加強委員之間的總額事務討論的交換意見的關係，有助於集體決策的產出。
    Decision making is a collective activity rather than an individual option. In literature, collective action can be symbolized as a network. The concept of network has emerged as an intellectual centrepiece in the field of public administration and the speedy development of social network analysis has facilitated “network research” to go beyond only a metaphor. However, most previous decision theories based on the concept of rationality have not seriously considered a network’s impact on the policy process. This research attempts to verify the causal relationship between social embeddedness and decision-making by examining how policy elites’ personal interactions shape individuals’ decision-making behaviour, influential power and the collective decision performance. This research focuses on the result of the mutual influence between rational and non-rational factors. Two cases (the Dental and Chinese Medicine Global Budget Payment Committees) are discussed by applying quantitative social network analysis in order to systemically expand the current understanding of the power distribution and its influential factors in these two decision making committees in Taiwan’s National Health Insurance domain.

    In regard to methodology, four participants’ social networks were designed not only to examine the social relationship between these committee members but also to analyse the phenomenon of social embeddedness in these two cases. There are totally 39 successful respondents (apx. 80% response rate, N=56) and these raw data were analysed by the indicators such as network centrality index, cliques, network density, block model, image matrix, MDS and QAP correlation, hierarchical regression in order to answer the research questions. Furthermore, this research is based on three analytical levels in social network analysis: “individual relationship”, “small group” and “global structure”, and not only explores the connection, power exercise and decision-making behaviour between these committee members but also analyses their role and position through the perspective of global network structure.

    The research verifies the hypothesis “decision-making is embeddeded in the structure of the actors’ interconnected social relationships” and utilizes the quantitative social network analytical method systematically to let network study go beyond a metaphor in the research field of public administration. I conclude that the distribution of the decision-making power and behaviour are both influenced by the committees’ social networks. Furthermore, the power distribution in the dental committee is two cores between the dental association and the BNHI, but the committee of Chinese Medicine is just one core of the Chinese Medicine association. With regard to attendance network as the independent variable, two factors significantly and positively influence the committee members’ attendance network: “decision-making influential network” and “resource exchange network”. Finally, the factors of “the NHI affair discussion network” and “the affair discussion clique centrality degree” have positive statistical significance but relatively the factors of “personal decision making influence” and “seniority” have negative statistical significance on the interviewees’ perception of the collective policy outcome.
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