實施健保IC 卡對民眾非正常就醫行為

The Impact of IC Cards Implementation on

謝佳玲(hsieh chia ling)

指導教授 ： 龔佩珍 ； 蔡文正

亞洲大學/健康學院/健康管理研究所/碩士(2007年)

摘要

背景與目的：全民健保實施後，大幅降低民眾就醫時的財務障礙及增加就醫可近性，在可充分自由就診的健保體制下，民眾可能為了治療而重複就診，造成門診使用過量的「非正常就醫行為」。因此，本研究除探討非正常就醫行為者之基本特性，並分析實施健保IC 卡對非正常就醫行為的影響。方法：本研究以2003 至2006 年健保資料中，每年10 月份之門診就醫次數超過20 次以上之「非正常就醫行為」者為研究對象，探討非正常就醫行為病患之基本特性如性別、年齡、是否為重大傷病、是否有慢性病等，並分析健保IC 卡實施前後非正常就醫行為者其就醫特性及疾病型態之改變。結果：非正常就醫行為者之年齡以「65 歲以上」為主，「男性」居多，四年間非正常就醫行為者其主要就醫疾病型態分別為「骨骼肌肉系統及結締組織之疾病」、「呼吸系統疾病」以及「損傷及中毒」，在就醫層級別方面以基層院所最多佔半數以上。健保IC 卡實施後，非正常就醫行為人數已由2003 年的2,500 人降至2006 年的1,511 人，平均就醫次數由2003 年的23.92 次降至2006 年的23.35 次，其整體總醫療費用亦由42,904,397 點下降至28,565,201點。但在非正常就醫行為者每人次醫療利用以及每人平均就醫醫師數、醫院數及科別數上卻呈顯著上升的趨勢。此外，以每人主要疾病別來看，以「腫瘤」、「精神疾患」、「症狀、徵候及診斷欠明之病態」之平均就醫次數最高。
結論與建議：健保IC 卡實施後，非正常就醫行為者之就醫人數、就醫次數及整體總醫療費用皆呈現下降趨勢。健保IC 卡實施的功能之一為對於非正常就醫行為者扮演即時監測的角色，但是非正常就醫行為者可能因為病情需要而使用必要與非必要的醫療資源，在無法限制民眾之就醫次數下，主管機關對於非正常就醫行為者應給予瞭解及輔導就醫觀念及醫療保健知識，加強病患對於自己健康之責任，以降低重複就醫醫療資源的浪費。

關鍵字

健保IC 卡、非正常就醫行為

並列摘要

Objective: After National Health Insurance implemented, the patients’financial burden was reduced and the accessibility of seeking medical treatment was increased. Under the current system of easy access to physicians, residence may have duplicate medical treatment. Therefore, the “abnormal frequent users” for outpatients came up consequently. The purpose of this study is to investigate the characteristics of abnormal frequent users for medical services and to analyze the effects of National Health Insurance (NHI) IC card on abnormal frequent users for medical services.
Methods: The dataset of this study was received from National Health Insurance. The subjects of this study were those “abnormal frequent users for medical services” who had more than 20 visits in October every year from year 2003 to 2006. The basic information for abnormal frequent users was gender, age, with serious injury diseases, with chronic diseases…etc. The study also analyzed the characteristics of medical demands and changes of disease types for those abnormal frequent users for medical services before and after NHI IC card implemented.
Results: The study showed that abnormal frequent users for medical services were mostly males, and in the age group of “above 65 years old”. Within four years, the main disease types for those abnormal frequent users for medical treatment were as follows: “diseases of the musculoskeletal system and connective tissue”, “diseases of the respiratory system” and “injury and poisoning”. In the part of levels of medical facilities, primary clinics and local hospitals had more than 50% of abnormal frequent users. After the implementation of NHI IC card, the numbers of abnormal frequent users for medical services decreased from 2,500 in year 2003 to 1,511 in year 2006. The frequency of seeing physicians in average decreased from 23.92 times in year 2003 to 23.35 times in year 2006. The total medical cost also decreased from 42,904,397 points to 28,565,201 points. The medical utilization per person-time, average physician/hospital/department visits per person for abnormal frequent users for medical services were increased significantly.
Otherwise, patients with main diseases such as “Neoplasms”, “Mental disorders”, and “Symptoms, signs, and ill-defined conditions” had the highest medical visits. Conclusions and suggestions: After implementing of NHI IC card, there had a tendency of numbers of visits, frequency of getting medical treatment and total medical cost were decreased. One of the functions of NHI IC card is to monitor those abnormal frequent users for medical services instantly. But abnormal frequent users for medical treatment may use necessary or unnecessary medical resources due to their medical conditions. Under the situation of government can not limited access to medical treatment in current health care system, the concepts of medical treatment, health information should be taught to those abnormal frequent users for medical services by government. Otherwise, the government or medical providers should increase the patients’ responsibilities of their own health as to reduce duplicate visits and unnecessary waste of medical resources.

並列關鍵字

National Health Insurance IC card, abnormal frequent users for

參考文獻

8. 李丞華、周穎政、陳龍生、張鴻仁(2004)：全民健保中醫門診利用率及其影響因素。臺灣公共衛生雜誌，23(2)：100-107。

15. 郝宏恕、翁瑞宏(2004)：全民健康保險中醫門診利用暨影響因素之研究。醫院，37(1)：27-42。

17. 張益誠、廖宏恩(2002)：西醫基層診所實施總額預算前後之價量變化—以臺灣北部地區西醫基層診所為例。臺灣公共衛生雜誌，21(5)：63-372。

18. 張鴻仁、黃信忠、蔣翠蘋(2002)：全民健保醫療利用集中狀況及高、低使用者特性之探討。臺灣公共衛生雜誌，21(3)：207-213。

21. 許志成、季瑋珠(1996)：門診高度使用者之特性：以大溪鎮群醫中心門診病人為例。中華衛誌，15(1)：91-95。