- 學位論文
影響高屏地區民眾健保申訴案件因素探討
Research on Critical Factors Affecting Complaint Cases Insured in Kaohsiung-Pingtung Area of National Health Insurance
摘要
本研究目的係在探討民眾申訴管道，分析其在診療類別、醫院層級、科別之申訴比率是否有差異，並由申訴民眾人口學特性及醫療資源分佈情況分析，針對病患基本特性、就醫行為及申訴行為進行交叉比對分析。 本研究以89年1月至90年12月的申訴資料為樣本共1188件，扣除資料不全之樣本後，獲得853份資料，採取JMP 4.0統計軟體進行描述性的分析及卡方檢定，以便於了解各因素間的關聯性。 由研究結果發現：申訴管道有全民健康保險局、消費者基金會、衛生局、醫院四種方式。其中以全民健康保險局方式佔最多有853件，其次為消費者基金會有11件，其他單位則無受理醫療申訴案件；就醫類別方面整體申訴百分比以西醫為最高有743件（87.10﹪），中醫最低為43件（5.05﹪），然而就申訴率（申訴件數/申報總件數）而言則以牙醫申訴率為百萬分之14.7佔最高，西醫申訴率為百萬分之6.9最少；醫療層級方面以基層診所申訴百分比為最高佔36.54﹪，地區教學醫院最低佔3.52﹪，但就申訴率以地區醫院最高為百萬分之20.4，基層診所最低為百萬分之3.7；科別方面申訴百分比以內科最高為34.82﹪，其次為外科（14.89﹪）、婦產科（10.55﹪）、骨科（9.26﹪）、牙科（7.85﹪），皮膚科最低為1.29﹪，就申訴率以牙科為百萬分之14.70佔最高，其次為中醫佔百萬分之13.61、骨科佔百萬分之12.18、婦產科佔百萬分之10.32、精神科佔百萬分之7.24，皮膚科仍為最低佔百萬分之3.24。診療類別分為門診及住院二方面，門診申報總件數最多為114099386件，申訴百分比較高佔63.9%，住院申報總件數為5342240件，申訴百分比為36.1%較少。就申訴率而言，以住院有較高的比率為百萬分之57.65，門診則較低為百萬分之4.93。 人口學特質方面，整體而言，性別來看申訴率男性大於女性；就年齡而言，年齡越大申訴百分比越高，但申訴率則以21-30歲群組最高佔百萬分之11.54，20歲以下群組最少佔百萬分之5.64。另從西醫、牙醫、中醫之性別及年齡申訴率來看，在性別申訴率方面西醫與中醫之申訴均以男性為主，牙醫則以女性為主要申訴對象；年齡申訴率方面西醫與中醫均以21-30歲群組之病患居多，牙醫則以31-40歲群組之病患為主佔百萬分之30.14；投保金額則以16500元∼22800元佔最多為48﹪；牙醫與中醫申訴民眾就醫地點申訴率，均以高雄市最多；申訴方式有電話、來局、來函三種，以電話居多為82﹪，來局最少為5.3﹪；申訴案件分類有陳情及檢舉，兩者比例差異不大；再者以牙科申訴案件治療項目申訴率而言，則以根管治療為最多佔百萬分之36.82，其次為假牙、牙齒咬合不正佔百萬分之31.44、填補（銀粉、樹脂）佔百萬分之10.86、拔牙佔百萬分之10.69，最少為牙周病佔百萬分之8.93。 進一步由卡方檢定來探討其病患基本特性、就醫行為及申訴行為交叉比對相互關係得知，投保金額方面，西醫、牙醫、中醫均以16500-22800元之投保人為主要申訴族群；醫院層級方面，西醫則以地區醫院申訴百分比較高，中醫、牙醫均以基層診所為主要申訴群體；權屬別方面，西醫、牙醫、中醫均以私立醫院為申訴群體；申訴原因方面，西醫以額外收費情形，牙醫、中醫均以不當蓋卡為主要申訴原因；申訴分類方面，西醫以陳情，牙醫、中醫均以檢舉為主要申訴途徑；申訴結案分類，西醫以復婉申訴人，牙醫、中醫均以移查核為主要結案分類。
並列摘要
The objective of this research was to discover ways that appeals are made，analyze according to the proportionate discrepancy via diagnosis and treatment，medical status and departments。Furthermore，there are also analyses of the relationship between the pleader and the medical source distribution，the cross validation of the pleader and types of diagnosis，hospital status and departments。 Research sampling is targeted on appeals made from January 2000 to December 2001。There are 853 completed samples，and JMP 4.0 was the software applied for statistical analysis。 Brief conclusion after the research：There are four ways that appeals can be made. Among these, the majority of appeals were received through the Bureau of National Health Insurance；the related variables and figures resulted from analysis are shown as follows；type of diagnosis and treatment claimed：Western medicine yields the highest percentage（87.10﹪）/ while traditional Chinese medicine yields the lowest（5.05﹪），However, among the rate of appeals made according to types of treatment (ie. cases claimed/total cases received): Dentistry yields the largest proportion（14.7ppm）/ while western medicine yields the lowest rate（6.9ppm）；From the medical status analysis：(of overall percentage)：clinics have yields the highest figure（36.54﹪），while regional teaching hospitals yield the lowest (3.52%). Among the rate of appeals made via hospital status: the result has shown that regional hospitals yield the highest rate（20.4ppm）/ while clinics are the lowest（3.7ppm）；On the analysis of departments versus appeals received：( of overall percentage)：Internal medicine yields the highest figure（34.82﹪）、 followed by surgery（14.89﹪）、gynemetrics（10.55﹪）、orthopedics（9.26﹪）、dental（7.85﹪）and dermatology（1.29﹪）.From the rate of appeals made according to types of treatment, dental departments yield the highest result （14.7ppm）、 followed by traditional Chinese medicine（13.61ppm）、orthopedics（12.18ppm）、gynemetrics（10.32ppm）、psychiatry（7.24ppm）and dermatology（3.24ppm）。 The above types of diagnosis and treatment were divided into two parts: outpatient service and hospitalized. Among these, the outpatient service received the most appeal cases of 114,099,386, which is approximately 63.9%; while the cases received from hospitalized patients is comparatively low (about 36.1%). According to the rate of appeals claimed, hospitalized yield a relatively high result of 57.65ppm, whereas outpatient service only got 4.93ppm。 On the characteristics of demography research：There is little discrepancy between the male and female proportion，however， research has found out that the older the age，the higher the percentage of appeals made, but the highest rate of appeals claimed falls on the age gap between 21 to 30 years old (11.54ppm), whereas those who are below 20 years old yield the lowest rate (5.64ppm). Besides, the analysis of the rate from the relationship of diagnosis versus age and sex variables has revealed that the majority of cases claimed on western medicine and traditional Chinese medicine are made by mals, whereas dentist appeals are mostly claimed by female clients. According to the rate versus age variable, the majority of appeals against western medicine and traditional Chinese medicine are made by those who are between 21~30 years old, whereas dentist appeals are made by those who are between 31~40 years old (30.14ppm). In respect of amount insured，the majority are insured for NT ＄16500∼22800（48﹪）；The highest rate of appeals claimed for dentistry and traditional Chinese medicine was found in Kaohsiung City. There are three ways to claim: either by a phone call, personal contact at the Bureau office, or through mail. Most people make appeals through telephone calls (about 82%) whereas personal contact at the Bureau office is the lowest (about 5.3%)；there is little variance between prosecution and pleading within appealing categories. Furthermore, as an example of the rate of appeals claimed on dentists, root treatment yields the highest rate of 36.82ppm, followed by false tooth prosthesis, malocclusion (approximately 31.44ppm), filling (amalgam or composite resin, the rate was about 10.86ppm), extraction (10.69ppm) and the least was periodontal disease (8.93ppm)。 After, applying Chi Square test and analyzing the research according to cross validation method among the following variables: basic characteristics of patients, their behaviors towards taking medical treatments and the appeals claimed. In respect of hospital status，the appeals claimed for western medicine come from regional hospitals，as for dentist、traditional Chinese medicine，the majority of appeals come from clinics；From the authority point，private hospitals are the major appealed target for western medicine 、dentistry and traditional Chinese medicine；As for the reasons of appeals claimed, overcharging is the main reason for western medicine，and not stamping on the National Health Insurance Card is the main reason for dentistry and traditional Chinese medicine；For the categories of appealing，pleading is the main way for western medicine，as for dentistry and traditional Chinese medicine，prosecution is the preferred choice；The difference between closing case categories and appealing cases：western medicine respond to pleaders in order to close the cases，while the majority of dentists and traditional Chinese medicine transfer for further investigation to close the cases。