台灣全民健保制度下的自付醫療費用與公平性研究

自付醫療費用(out-of-pocket, oop)是權衡健康照護財務政策的重要指標，本文探討全民健保制度下，不同所得階層民眾的自付醫療費用差異。以醫療院所的就醫費用單據實填金額資料，提供相對於家庭收支調查較為準確與低成本的調查報告。收集4,535筆問卷資料，其中有2,256(49.7%)人為門診費用分析影響因素的觀測對象；2,279(50.3%)人過去一年內有住院的醫療利用花費，歸類為住院費用影響因素的觀測對象。應用三部份模型(three-part model)於分析醫療費用的影響因素，家庭所得收入越高，自付醫療費用越多，年所得每增加一仟元，一年平均自費多付742元；年齡每增加1歲，一年平均的自付醫療費用增加89元；男性比女性一年平均多付自費1,586元；自評生理健康狀態(PCS)分數越高，代表自評生理健康狀態愈佳，三部份模型計算生理健康狀態每多1分，自費支出一年平均少付385元；教育程度越高付的自付醫療費用越多，每增加1年的教育年數，平均一年少付134元；有購買補充醫療保險的樣本相較於沒有購買補充醫療保險的族群，一年平均多付自費1,108元；居住郊區或農村的人口群，比居住市區平均一年自費支出多1,512元。本研究設計的第二個模型是為了探討在台灣的全民健保制度下，分析社經狀態(Social Economic Status, SES)對自付醫療費用(out-of-pocket, oop)的影響，並以路徑分析模型(path analysis model) 探討社經狀態是否透過「生理健康狀態」、「心理健康狀態」以及「付費能力」的中介效果，影響民眾使用健康服務的財務負擔差異。統計總邊際效果，高社經階層比低社經階層的人口群平均每年多花費自付金額$3,721元。男性比女性多付$1,299元，每多一歲的人就平均多付$320元，自評生理健康狀態每多一分每年少付516元，自評心理狀態每多一分則每年少付$47元；付費能力強的家庭比較差的家庭多付$3,308元。社經狀態正向影響身心健康狀態與付費能力，高階層社經狀態者負擔較高額的自掏腰包醫療費用，可以推論全民健保制度下的自付醫療費用支出為累進分配。然而這個結果並不能直接證明台灣健保制度的效率面一樣是正向的，因為至今台灣仍然沒有健全的分級醫療以及轉診制度，社經弱勢者因為付費能力弱勢，是否同等的健康需求均獲得平等的健康照護，是否已經使用應該獲得的醫療資源或是因財務障礙受到排擠而縮減醫療利用，需要更多的實證依據來回答。

關鍵字

自付醫療費用；社經階層；健康不平等；健康公平；醫療財務負擔；全民健保；職業分類

並列摘要

Out-of-pocket medical costs are one of the important indicators weighing health care financial policy, this article discusses the difference of out-of-pocket (OOP) expenditure between different income classes (socioeconomic status, SES) under national health insurance (NHI) system. Based on the actual amount of medical expenses in medical institutions, the survey method shall be more accurate and low-cost in comparison to the household income and expenditure survey. The data of 4,535 questionnaires were collected, among which 2,256(49.7%) were the observation objects of influencing factors for the analysis of outpatient costs. Medical utilization cost over the past year for 2,279(50.3%) persons was utilization cost, classified as the observed object of influencing factors of hospitalization expenses. The three-part model is applied to analyze the influencing factors of medical expenses. The higher the family income is, the more the out-of-pocket medical expenses will be. For every NT$1,000 yuan increase in annual income, the annual average out-of-pocket expenses will be $742 more. For every 1 year increase in age, the average out-of-pocket medical expenses increased by $89. Men pay an average of $1,586 more per year than woman. The higher the score of physical health score (PCS) is, the better the physiologic health status will be. For each additional point of PCS calculated by the three-part model, the OOP will pay $385 less in a year on average. The higher the education level is, the more the average out-of-pocket medical expenses are. For each additional year of education, the average annual less payment is $134. Participants who had complementary insurance paid an average of $1,108 a year more than those who did not. This study found that the higher the income, the more out-of-pocket medical expenses, income levels and changes in financial burden may affect the equity of accepting the medical service if the high-income groups' out-of-pocket payment of medical services is "necessary," implied low income to buy less out-of-pocket medical may affect health status. On the contrary, it is "unnecessary" to choose to purchase medical services due to the ability to pay, and disputes may occur over the risk of ostracizing medical resources of the disadvantaged minority. This paper aims to analyze the impact of Social Economic Status (SES) on out-of-pocket (OOP) medical expenses under Taiwan's national health insurance system. Path analysis model was used to explore whether socioeconomic status had mediating effects on people's financial burden of using health services through "physical health score (PCS)", "mental health score (MCS)" and "pay ability". According to the total marginal effect, high socioeconomic status is $3,721 more per person than low socioeconomic status. However, the indirect effect of socioeconomic status on out-of-pocket costs through physical health is that the upper classes pay an average of $385 per person per year less than the lower classes. Socio-economic states have an indirect effect on out-of-pocket costs through mental health. The upper classes pay an average of $75 per person per year less than the lower classes. Socioeconomic status has an indirect effect on out-of-pocket (OOP) expenses through the ability to pay, with the upper classes paying an average of $516 per person per year more than the lower classes. Although the social and economic status positively affects the physical and mental health status and the ability to pay, the upper-class social and economic status still bears high out-of-pocket medical expenses, which can be inferred that the social and economic disadvantaged groups under the national health insurance system do not bear more inequality because of the health disadvantaged. Financial burden in the Taiwan national health insurance system roughly conforms to the principle of fairness, although in a low social status and health status of poor population burden more part of pay medical treatment fee, because of its degree of burden in low socioeconomic status people acceptable range, can be concluded as a result, this result is that out-of-pocket payments was progressive proportion base on national health insurance in Taiwan. But, it does not directly prove the efficiency of Taiwan's health care system as a positive side. Since there is still no sound classification medical in Taiwan so far, levels of care and referral system in Taiwan so far. However, this result cannot directly prove that the efficiency of Taiwan's health care system is positive because Taiwan still does not have a sound hierarchical medical treatment and referral system. Are socially and economically disadvantaged people receiving equal health care for the same health needs because of their poor ability to pay? Are medical resources being used as they should be or are they being curtailed because of financial barriers? More empirical evidence is needed to answer these questions.

並列關鍵字

out-of-pocket ； socioeconomic status ； health inequality ； health equity ； health financial burden ； national health insurance ； occupational classification