全民健康保險門診高利用者型態之研究

The Study of Type of Frequent Attenders among Outpatients Care under National Health Insurance in Taiwan

于家偉(Chia Wei Yu)

指導教授 ： 劉見祥

亞洲大學/健康學院/健康管理研究所/碩士(2009年)

摘要

研究背景：由於台灣醫療體系擁有與其他國家比較起來獨特的特性，因此民眾有較強選擇醫療照護者的權利，加上台灣家庭醫師以及轉診制度尚未完善，在獨特的醫療體系下，造就我國門診醫療平均就診次數高、就診於醫院（特別是醫學中心）的比率高以及更換醫師與醫療院所頻繁等三大特色。在這種背景下，門診高利用者的問題是值得相關衛政單位所關注的。
研究目的：一、藉由就醫院所數與科別數之高低，將門診高利用者區分為四類，並分析此四類高利用者之影響因素以及四類門診高利用者門診次數與門診醫療費用之情況。二、在與國外相同計算基礎下，國內高利用者就醫情況之探討。三、研究結果期望給予相關衛政單位在政策以及輔導上之幫助。
研究方法：本研究定義門診申報就醫次數≧150次者為高利用者，資料來源為以民國95年以及96年國家衛生研究院（National Health Research Institutes, NHRI）全民健康保險學術資料庫之CD檔、ID檔以及HOSB檔，並以統計分析軟體SPSS 12.0對資料進行描述性、推論性統計分析。
結果與結論：一、若單純以國外看診的狀況計算就醫次數來看，高利用者平均每位高利用者每年就診次數亦從原先179.61次下降至166.15次。二、影響醫療院所高低之因素有性別、年齡、投保類別、投保地區、重大傷病、精神疾病以及慢性病數。三、影響醫療科別高低之因素有性別、年齡、投保類別、投保地區、重大傷病、慢性疾病數以及精神疾病。四、四類高利用之特性為：相較於少院少科高利用者，年齡、投保地區、投保類別、精神疾病、重大傷病以及慢性疾病數能有效預測多院少科以及少院多科高利用者；性別、年齡、投保地區、投保類別、精神疾病以及慢性疾病數能有效預測多院多科高利用者。五、多院多科高利用者之就醫次數比其他三類高利用者高，醫療費用以少院多科高利用者最高，多院多科次之，多院少科最少。
建議：根據研究結果對於相關衛政單位做以下建議：在政策方面：1.改變就醫次數計算之方式：2.落實共同會診制度。3.輔導作業納入家庭醫師試辦計畫。而在輔導工作上針對不同型態之高利用者依據其特性進行不同方式之輔導。

關鍵字

門診高利用者 ； 健保資料庫

並列摘要

Background:
Since the medical system in Taiwan is more unique than that in other countries, people in Taiwan have more rights over choosing their own medical care providers. Besides, with the immaturity of both the family physician system and the referral system in Taiwan, this unique system is characterized by the large average number of outpatient visits, the high rate of hospital attendance (especially the medical center attendance), and the high frequency of changing physicians and health care facilities. In this context, the issue of frequent attenders (FAs) of outpatient services deserves the concern of relevant healthcare competent authorities.
Purposes:
This study divided FAs of outpatients services into four categories by the number of health care facilities and outpatient specialties, which were FAs who had consulted more facilities and more specialties (MFMS), FAs who had consulted more facilities and less specialties (MFLS), FAs who had consulted less facilities and more specialties (LFMS), and FAs who had consulted less facilities and less specialties (LFLS), to analyze the influencing factors of these four categories of FAs, the number of outpatient visits and outpatient medical expenses in these categories of FAs. With the same calculation base for foreign FAs, this study is designed to examine the hospital attendance of domestic FAs. In addition, the study findings hopefully can serve as references for relevant healthcare competent authorities to develop policies or provide counseling services.
Methods:
According to the definition of this study, frequent attenders (FAs) refer to patients who have 150 times of outpatient visits or more per year. The research resources of this study originated from the CD files, ID files, and HOSB files of academic database of Taiwan’s National Health Insurance in the National Health Research Institutes (NHRI) in 2006 and 2007. The data obtained from NHRI were processed by the statistical software SPSS 12.0 for descriptive and inferential statistical analyses.
Results and Conclusions:
1. Based on the same calculation basis for other countries, the average number of outpatient visits of per FA per year decreased from 179.61 times to 166.15 times.
2. The influencing factors of FA’s number of visits in health care facilities were gender, age, insurance type, insurance area, major illness and injury, mental disorder, and the number of chronic diseases.
3. The influencing factors of FA’s number of visits in specialties were gender, age, insurance type, insurance area, major illness and injury, the number of chronic diseases, and mental disorder.
4. The properties of the four categories of FAs: In comparison with LFLE FAs, influencing factors such as age, insurance area, insurance type, mental disorder, major illness and injury, and the number of chronic diseases could more effectively predict MFLS FAs and LFMS FAs while influencing factors such as gender, age, insurance area, insurance type, mental disorder, and the number of chronic diseases could more effectively predict MFMS FAs.
5. The number of outpatient visits of MFMS FAs was greater than FAs in the other three categories. The medical expenses of LFMS FAs were the highest, followed by those of MFMS FAs, and the medical expenses of MFLS FAs were the lowest.
Recommendations:
According to the study findings, the following recommendations are proposed for the consideration of relevant healthcare competent authorities: In the aspect of policy-making, it is recommended to 1. adjust the calculation basis for the number of outpatient visits; 2. put joint consultation system into practice; 3. include the counseling operation into the “Family Physician Integration Trial Plan (FPITP)”. In the aspect of counseling, it is recommended to apply different counseling methods to different categories of FAs according to their respective properties.

並列關鍵字

frequent attenders of outpatient services ； NHIR database

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