醫療院所誘發保險醫療支出差異性研究

Hospitals and medical expenses induced Insurance Research of Differences

林祐孺(Yu-Ju Lin)

指導教授 ： 汪琪玲

淡江大學/商學院/保險學系保險經營碩士在職專班/碩士(2011年)

https://doi.org/10.6846/TKU.2011.00691

摘要

根據保發中心統計健康險保費收入由84年健保開辦時的45.1億元，躍升到97年的1,973.3億元，14年間保費成長近44倍，因而全民健保的開放更喚起大眾對健康險的需求增加。國民醫療保健支出（NHE）受國民所得持續增加，國民相對重視生活品質的提昇；且人口結構逐步老化與醫療技術進步的影響，致使醫療保健支出的節節升高。因全民健保開放後，部分有心人士利用醫療資源濫用保險醫療資源，或有些營業不當之醫療機構為了生存而與病患製造假診斷以共謀利。

建議主管機關應協助保險公司與健保局建立聯繫機制，定期與保險公司作雙向的資訊交流與溝通，建立不良醫療機構與濫用醫療資源名單資料庫等。

保險公司與保戶的爭議問題確是醫療專業行為，因此健康險的商品設計、核保、理賠等均較為複雜且費時，主要是因為健康險的道德危險及逆選擇因素較難區別但是比率同時也較高。本文利用卡方檢定，來檢證保險理賠時醫療支出的高低、與進行醫療之醫療院所的關係。

保險公司對於風險保戶之管理：可透過特定個案服務，將可降低罹病或併發症風險，並可降低醫療理賠支出及降低保險公司支出費用與降低保發申訴或保險局處理申訴之成本。

而醫療機構之醫師若發現病患有就診異常狀況時，應會診其他科別之醫師，讓病患接受適當的心理輔導，以避免不必要的醫療支出而增加社會成本，讓台灣的健保制度可更健全。根據以上分析，私立醫療院所以〔營利〕為導向目的。故在治療過程中，有較多動機及需求，使住院與門診與手術給付支出較公立醫療院所高．以致保險公司於各保單理賠件數及金額皆呈現此現象

同時也會透過理論與文獻之探討，以共同尋求保險業未來如何面對保險理賠之適切作法。提供部門做為日後修法或檢討商品條款規定之參考。

關鍵字

醫療院所 ； 保險醫療支出 ； 健康險

並列摘要

According to Paul, center statistics health insurance premiums from 84 years when the NHI was 45.1 billion yuan, jumped to 97 years of 1,973.3 billion yuan, nearly 14 years, premium growth of 44 times, thus opening up more to arouse the national health insurance mass health insurance increased demand. National health expenditures (NHE) by per capita income continued to increase, the relative importance of national quality of life improved; and the gradual aging of the population structure and the impact of advances in medical technology, resulting in health care spending has been rising. Open for national health insurance, some of people have medical insurance, use of medical resources, misuse of resources, or some improper business in order to survive and medical institutions and patients diagnosed with conspiracy to create false profits.

Recommended that the competent authorities shall assist the insurance companies to establish liaison mechanisms with the Health Insurance Bureau, on a regular basis with the insurance company for two-way exchange of information and communication, medical institutions and the establishment of non-performing list misuse of medical resources, databases and so on.

Insurance companies and policyholders is indeed controversial issue of medical professional conduct, the health insurance product design, underwriting, claims etc are more complex and time-consuming, mainly because of moral hazard and health risk factors, adverse selection is more difficult to distinguish but the ratio also higher. In this paper, chi-square, to evidence the insurance claim check when the level of medical expenditures, and the hospital's medical relationship.

Policyholders of insurance companies for risk management: the case through a specific service, will reduce the risk of morbidity or complications, and reduce health care expenditures and lower insurance claims and lower insurance made a complaint or appeal of the cost of the insurance bureau.

The medical institutions of the physician if a patient has abnormal status treatment, should the physician consultation other divisions, so that patients receive appropriate counseling, in order to avoid unnecessary medical expenses and increasing social costs, so that Taiwan's health care system can more robust. Based on the above analysis, so the private medical hospital] [profit-oriented purposes. Therefore, in the course of treatment, have more motivation and needs, so that inpatient and outpatient and surgical hospitals pay higher than public spending. That insurance companies in the insurance policy number and amount of all claims presented to this phenomenon

But also through the study of theory and literature, to jointly seek the insurance industry in the future how to deal with insurance claims of appropriate practices. Amending the law department as to provide future goods or review the terms of reference.

並列關鍵字

Hospitals ； Life Insurance

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