- 學位論文
癌症中醫門診理賠因素之探討
The research of Claims Factor in Chinese Cancer Clinic
摘要
台灣地區十大死因癌症已蟬聯多年之首，癌症險成為每人必備保單之一。隨著二代健保上路，醫療體系住院標準相較過去變的更嚴格，在保戶住院條件變嚴格情況下，癌症中醫門診成為投保癌症險保戶新的看診選擇，更成為癌症險門診理賠支出的龐大負擔。中醫門診多為療養屬非必要性治療，這與癌症險條款約定中，針對癌症病症的門診治療理念不符。對此，保險公司會有特定合作的中醫師，針對癌症險理賠浮濫的中醫門診，進行醫務諮詢醫師專業見解。本研究主要目的可歸納以下二點：一、彙整既有癌症中醫門診醫務諮詢資料，分析影響中醫師判斷癌症中醫門診給付條件的變數，並探討各變數與給付次數的關聯性。二、利用背景交叉分析與專家訪談，分析哪些變數對於中醫師在判斷癌症中醫門診是顯著的，及合理給付次數之關聯性。 本研究彙整某人壽保險公司2013年至2017年癌症中醫門診醫務諮詢資料，將醫務諮詢醫師建議次數依給付頻率分類，並分別與諮詢單上面的變數做敘述性統計分析、交叉分析與無母數卡方檢定加以了解其關聯性，再就本研究樣本數中找出與四個顯著變數符合與不符合的案例作研議，最後擬定訪談大綱，擇定不同領域之專家作深度訪談。發現四項結論： 一、該公司醫務諮詢醫師回覆建議全部給付比例為42.8%。二、本研究影響該公司醫務諮詢醫師建議首要因素為客戶五年內有無接受西醫放化療、次要因素為五年內有無罹患癌症。三、癌症中醫門診使用特殊中藥不會影響醫師建議次數。四、西醫為主中醫為輔的合併治療是現今治療癌症完整的療程。 本研究提供理賠人員在面對癌症中醫門診案例時，可參考本研究結果，判斷理賠金額與次數之合理性，進而降低癌症中醫門診醫務諮詢的次數與成本，增加理賠效率。
並列摘要
The top ten causes of cancer have been ranked first for many years in Taiwan, leading to cancer insurance has become one of the mandatory policies for each person.In 2013,the ealth insurance system was changed to the DRGs system.Therefore, hospitalization standards have become stricter than in the past.Under this premise,the Cancer Chinese Medicine Clinic has become a new option for cancer insurance insured, and it has become a huge burden on the out-of-pocket expenses of cancer insurance.There are mostly convalescent and non-essential treatments of the Chinese medicine clinics.This is inconsistent with the concept of outpatient treatment for cancer diseases in the cancer insurance clause agreement.Therefore,the insurance company will have a specific cooperation of Chinese medicine practitioners to provide professional insights in order to avoid over-claims for cancer insurance in Chinese medicine clinics. The main purpose of this study can be summarized as follows: 1. This study gathers medical consultation information for existing cancer clinics in Chinese medicine.The study analyzed the variables that affect Chinese medicine doctors' judgment on the conditions of traditional Chinese medicine for cancer clinics, and explore the relationship between the variables and the number of payments. 2. This study cross-analyzed the background of the insured and in-depth interviews with experts to analyze which variables were relevant to Chinese medicine practitioners in judging the outpatient clinic for cancer and the number of reasonable payments.This study summarized the medical consultation information of a life insurance company's Cancer Chinese Medicine Clinic from 2013 to 2017.Through narrative statistical analysis, cross-analysis, chi-square test and conduct in-depth expert interviews to understand the relationship between variables, the final findings are as follows: (1)A total of 42.8% of Chinese Medicine physicians will reply to the proposal for all payments in the case of the company’s. (2)The primary factor is whether the client receives radiotherapy and chemotherapy within five years,and the secondary factor is whether or not he has cancer within five years.This is the main variable that affects the number of responses to Traditional Chinese Medicine physicians. (3)It does not affect the number of Chinese doctors’ suggestions on whether or not to use special Chinese medicines. (4)Western medicine is mainly supplemented by traditional Chinese Medicine, it is a complete course of treatment for cancer. In the future,when faced with a case of similar Chinese cancer clinics,the results of this study can be used to determine the reasonableness of the claims and the number of claims,thereby reducing the cost of medical consultation for traditional Chinese medicine in cancer clinics.