楊銘欽Yang, Ming-Chin臺灣大學:醫療機構管理研究所徐麗滿Hsu, Li-ManLi-ManHsu2010-05-052018-06-292010-05-052018-06-292009U0001-1708200923580500http://ntur.lib.ntu.edu.tw//handle/246246/180896研究背景與目的：全民健保開辦的目的，是要集合社會大多數人的力量，降低民眾就醫的經濟障礙，以照顧全體民眾的健康。然而，隨著經濟不景氣，民眾可能因為長期失業或家庭變故等原因導致經濟發生困難，未能按時繳交保險費，暫時無法以健保身分就醫。本研究主要目的在探討經濟困難者在辦理欠繳保險費協助措施前後一年期間之醫療利用變化情形及與一般民眾之差異，及其相關因素。究方法：健保紓困貸款與分期攤繳保險費是目前經濟困難民眾欠繳保險費時最主要的協助措施。本研究以2007年向健保局台北分局申請辦理紓困貸款或分期攤繳保險費且在該分局加保的被保險人及其當時之眷屬為研究對象，分析其於辦理協助措施前後一年期間之醫療利用資料。對照組係以在相同分局加保之保險對象為抽樣母體，按母群體之性別年齡分布進行分層系統性抽樣。本研究之紓困組計有1,116人，分期組計有93,198人，對照組計有93,336人。本研究以紓困者或分期者與一般民眾各項醫療利用之差異中的差異分析(Difference in Difference, DID)，及「總醫療費用」、「門診醫療費用」、與「住院醫療費用」等3個醫療利用指標為依變項之線性複迴歸模型分析的結果，來探討保險對象於辦理欠繳保費協助措施前後一年期間內，醫療利用的變化情形與相關因素。究結果：1.欠繳保險費民眾在辦理協助措施後，會增加總就醫率、各類門診之就醫率、各類門診就醫次數、各類門診費用點數、急診就醫次數、及住診利用機率等類之醫療利用；與一般保險對象之醫療利用的差異，會顯著縮小，其中急診就醫次數、及住診利用機率，甚至會高於一般民眾。2.多變項迴歸分析顯示欠費者在辦理紓困貸款或分期攤繳措施後的總醫療費用、門診費用均會顯著增加；總醫療費用以分期者增加的幅度比較大；門診醫療費用則是以紓困者增加幅度比較大；而分期者的住院醫療費用亦會增加，但紓困者的住院費用雖有增加但並未出現一致增加的變化趨勢。3.住院與急診醫療利用的最高峰是出現在辦理紓困或分期前一個月，其次為紓困或分期後第一個月。而門診醫療利用的最高峰是在辦理紓困或分期後第一個月。4.醫療費用會受到前傾因素、能用因素、及需要因素的影響，不同年齡、性別、種族，身心障礙程度，慢性病種類、或是否有重大傷病在總醫療費用、門診及住院醫療費用上有顯著的不同；而不同投保類別則在總醫療費用及住院醫療費用上有顯著的不同；設籍省市別則會對民眾的門診醫療費用有顯著影響。究結論：整體而言，紓困貸款及分期攤繳2類措施，確能協助保險對象在欠繳保險費時排除就醫的障礙，而且，還款條件較優惠的紓困貸款措施對民眾在就醫率與就醫次數等項目的幫助程度會高於分期攤繳。而民眾確因急重症醫療需求而申請辦理紓困及分期攤繳，這兩項措施也確實協助民眾解決欠繳保險費時急重症醫療需求的問題，提供民眾及時的急重醫療幫助。議事項：1.建議主管機關持續辦理欠繳健保費協助措施，讓經濟弱勢民眾及時申請相關補助，避免因繳不起保險費而無法享受健保的照護。2.建議針對山地原住民欠繳保險費的情形予以特別關注，提供適切保險費協助措施。Background and objectives: The goal of the National health insurance (NHI) is to gather the strength of the whole society, so to help reduce the economic barrier when seeking medical services. The ultimate goal of NHI is to take care of the health of the public. However, along with the economic depression, many people could face difficulties derived from long-term unemployment or unexpected family crisis. They may not be able to pay the insurance premium on time, and temporarily can not use their insured status when seeking medical care. This research aims to explore the differences in the healthcare utilization one year before and after the disadvantaged insured apply for the assistance schemes and to compare their medical usage with the ordinary person, as well as to discuss relative factors.ethod: Currently, the relief funds loan and installment are the major assistance schemes available to help those who are facing difficulty in paying the premium on time. The study subjects of this research were the insured and their family dependants applying for the relief funds loan and the installment in the Taipei branch of NHI Bureau in 2007. Totally 1,116 persons were included in the relief funds loan group, and 93,198 persons in the installment group. The data of their healthcare utilization one year before and after applying for assistance schemes were collected. The subjects in the control group were sampled from the insured population in the same branch stratified by genders and age groups. Totally 93,336 persons were selected in the control group, whose medical expenditure data were retrieved and compared with that of the experimental groups by detailed analyses as follows. In finding out the differences in healthcare utilization and the relative factors during one year before and after receiving assistance schemes for those insured who owed premium, there are several indicators to be adopted and observed. The “difference in difference” analysis was used to compare the healthcare utilization of persons with loan or installment and the control group. Three indices of healthcare utilization, “total medical expenditure”, “outpatient service medical expenditure” and “hospitalization expenditure”, were the dependant variables for the linear multivariate regression model.esults: 1.It is found that total medical treatment and outpatient services, number of outpatient clinic visits, relative value units of outpatient clinics, number of emergency visits, and hospitalization all increased after the disadvantaged insured received the assistance. It’s also found that the differences of healthcare utilization between the experimental group and the control group reduced significantly. Especially, number of the emergency visits and hospitalization rate were even higher in the experimental group. 2. Multivariate regression analyses revealed that total medical expenditure and outpatient expenditure increased significantly for experiment group. Specifically, those who in installment had more increment of their total medical expenditure, but such increase was more obvious in the clinical expenditure of those who applying relief funds loan. Hospitalization expenditure increased for installment applicants, but the insured with relief funds loan had increased hospitalization expenditure without consistent changing pattern. 3. The peak of utilization of hospitalization and emergency visits appeared at one month before applying the relief loan and installment. The second peak appeared at the first month of the schemes. The peak utilization of outpatient was at the first month after the relief loan and installment. 4. The medical expenditures were affected by predisposing factors, availability factors and demand factors. Significant differences were observed in total medical expenditure, outpatient expenditure and hospitalization expenditure with respect to age, gender, race, the degree of physical and psychological disabilities, the types of chronic illness, or severe illness. Different categories of the insured had significantly different expenditure of total medical services and hospitalization; while geographical differences greatly influenced the outpatient clinic visits.onclusion: Generally speaking, the relief funds loan and the installment surely can reduce the economic barriers when seeking medical treatment for the insured who can not pay premium on time . Moreover, lenient repayment terms on the relief loan could provide even greater help than the installment program in the utilization rate and number of medical services. Indeed, those who applied for the loans and the installments were the ones desperately needing the services due to severe illness. These two schemes practically assisted the owed-premium insured with healthcare of emergent and severe illness in time.ecommendations: 1. The competent authority should continuously implement owed-premium assistance schemes for economically disadvantaged population. 2. The problems of owed premiums for aborigines require special attention and could be solved partially by feasible premium assistance schemes.目 錄試審定書 i謝 ii文摘要 iiibstract v一章 緒論 1一節 研究背景與動機 1二節 研究目的 2二章 文獻探討 4一節 健保體制下弱勢族群協助措施 4二節 醫療利用之理論模式 6三節 醫療利用相關實證研究 7三章 研究材料與方法 13一節 研究架構 13二節 研究假說 15三節 研究變項與操作型定義 15四節 研究材料及研究對象 22五節 統計分析方法 28四章 研究結果 37一節 研究對象之基本特性 37二節 醫療利用概況與趨勢 40三節 協助措施介入前後之改變的差異中差異分析(DID)結果 45四節 迴歸模型分析結果 48五章 討論 52一節 研究資料品質之討論 52二節 重要研究結果之討論 53三節 研究限制 62六章 結論與建議 64一節 結論 64二節 建議 66考文獻 68目錄3-1辦欠繳保險費協助措施對經濟困難者醫療利用影響之研究架構 133-2辦理欠繳保險費協助措施者醫療利用相關因素之研究架構 143-3實驗組研究對象篩選流程與資料處理程序 263-4對照組研究對象篩選流程與資料處理程序 274-1 總就醫率變化趨勢圖 744-2 門診就醫率變化趨勢圖 744-3 住院就醫率變化趨勢圖 744-4 急診就醫率變化趨勢圖 754-5 西醫門診就醫率變化趨勢圖 754-6 牙醫就醫率變化趨勢圖 754-7 中醫就醫率變化趨勢圖 764-8 門診就醫次數變化趨勢圖 764-9 住院就醫次數變化趨勢圖 764-10 急診次數變化趨勢圖 774-11 西醫門診就醫次數變化趨勢圖 774-12 西醫門診初級照護就醫次數變化趨勢圖 774-13 牙醫就醫次數變化趨勢圖 784-14 中醫就醫次數變化趨勢圖 784-15 總醫療費用變化趨勢圖 784-16 門診醫療費用變化趨勢圖 794-17 住院醫療費用變化趨勢圖 794-18 急診醫療費用變化趨勢圖 794-19 西醫門診費用變化趨勢圖 804-20 牙醫門診費用變化趨勢圖 804-21 中醫費用變化趨勢圖 804-22 平均住院日數變化趨勢圖 81目錄3-1 研究變項之操作型定義 203-2 本研究資料來源與使用之欄位 233-3 對照組抽樣樣本與抽樣母群體投保類別分布情形 253-4 差異中的差異(Difference in Difference)之說明 30 4-1-1 研究樣本的特質及基本資料檢定分析 82 4-2-1 研究對象於辦理欠費協助措施前後之就醫率 84 4-2-2 研究對象於辦理欠費協助措施前後之就醫次數 85 4-2-3 研究對象於辦理欠費協助措施前後之醫療費用 86 4-3-1 紓困貸款者及分期攤繳者與一般民眾之組間醫療差異，於協助措施介入前後3個月差異中之差異(Difference in Difference)分析 87 4-3-2紓困貸款者及分期攤繳者與一般民眾之組間醫療差異，於協助措施介入前後6個月差異中之差異(Difference in Difference)分析 88 4-3-3 紓困貸款者及分期攤繳者與一般民眾之組間醫療差異於協助措施介入前後12個月差異中之差異(Difference in Difference)分析 89 4-3-4 紓困貸款者或分期攤繳者與一般民眾醫療利用之DID分析結果 90 4-4-1 辦理紓困貸款及分期攤繳者與一般民眾總醫療費用之逐步迴歸分析 91 4-4-2 辦理紓困貸款及分期攤繳者與一般民眾門診醫療費用之逐步迴歸分析 94 4-4-3 辦理紓困貸款及分期攤繳者與一般民眾住院醫療費用之逐步迴歸分析 975-1 總醫療費用之強影響力觀察值明細表 100 錄錄 1 中央健康保險局協助各級政府辦理保險對象健保費補助項目一覽表 101錄 2 全民健康保險免除自行部分負擔的項目 104錄 3 健保紓困貸款與分期攤繳相關規定 105錄4-1-1 每月之就醫率-總就醫率、門診就醫率、住診就醫率 (就醫率=就醫人數/總人數) 108錄4-1-2 每月之就醫率-急診就醫率、西醫門診就醫率、西醫門診初級照護就醫率 (就醫率=就醫人數/總人數) 109錄4-1-3 每月之就醫率-牙醫門診就醫率、中醫門診就醫率 (就醫率=就醫人數/總人數) 110錄4-2-1每人每月平均就醫次數-門診、住診、急診 111錄4-2-2 每人每月平均就醫次數-西醫門診、牙醫門診、中醫門診 111錄4-2-3 每人每月平均就醫次數-西醫門診初級照護 113錄4-3-1 每人每月平均醫療費用點數-總醫療費用、門診費用、住診費用 114錄4-3-2 每人每月平均醫療費用點數-急診費用、西醫門診費用、牙醫門診費用 115錄4-3-3 每人每月平均醫療費用點數-中醫門診醫療費用點數、每人每月平均住院日數 116錄5-1 協助措施介入前後醫療利用之變化，於實驗組與對照組之差異-紓困貸款者紓困前後3個月就醫行為分析 117錄5-2 協助措施介入前後醫療利用之變化，於實驗組與對照組之差異-紓困貸款者紓困前後6個月就醫行為分析 118錄5-3 協助措施介入前後醫療利用之變化，於實驗組與對照組之差異-紓困貸款者紓困前後12個月就醫行為分 119錄5-4 協助措施介入前後醫療利用之變化，於實驗組與對照組之差異-分期攤繳者分期前後3個月就醫行為分析 120錄5-5 協助措施介入前後醫療利用之變化，於實驗組與對照組之差異-分期攤繳者分期前後6個月就醫行為分析 121錄5-6 協助措施介入前後醫療利用之變化，於實驗組與對照組之差異-分期攤繳者分期前後12個月就醫行為分析 122錄5-7 協助措施介入前後醫療利用之變化，於實驗組與對照組之差異-一般投保身份者前後3個月就醫行為分析 123錄5-8 協助措施介入前後醫療利用之變化，於實驗組與對照組之差異-一般投保身份者前後6個月就醫行為分析 124錄5-9 協助措施介入前後醫療利用之變化，於實驗組與對照組之差異-一般投保身份者前後12個月就醫行為分析 125application/pdf2261837 bytesapplication/pdfen-US全民健康保險欠繳保險費紓困方案醫療利用national health insurancepremium assistance schemeshealthcare utilizationthesishttp://ntur.lib.ntu.edu.tw/bitstream/246246/180896/1/ntu-98-P96843001-1.pdf