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題名:全民健康保險醫療費用給付稽核流程之研究
作者:傅懷慧 引用關係
作者(外文):Hwai-hui Fu
校院名稱:國立中山大學
系所名稱:企業管理學系研究所
指導教授:蔡憲唐
韋伯韜
學位類別:博士
出版日期:2004
主題關鍵詞:激勵機制全民健康保險抽樣計劃National Health InsuranceIncentive mechanism designSampling plan
原始連結:連回原系統網址new window
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中文摘要
台灣實施全民健康保險已屆滿8年,目前超過96%的國民加入此健康保險體系,且有70%的民眾對此制度感到滿意,是一個具相當高評價的健康保險體系。但因人口老化、經濟發展、健康保險擴張,醫療資源成長,以及醫療科技創新等因素,造成醫療保健支出逐年攀升,在屢次無法通過立法院審議調漲保險費率的情況下,中央健康保險局(簡稱:健保局)只好從節流角度來謀求健保財務收支平衡。目前健保局實施「總額管制」來控制醫療服務費用給付總金額,並設立醫療服務審查委員會(簡稱:醫審小組),負責審查醫療費用申請內容,藉以評定給付標準。但面對日益增多的稽核業務量,如何提升稽核效率是健保局改善重點,亦是本論文研究重點。
本研究擬建立一套公平合理醫療費用給付之稽核流程。提出MCPA流程(“Medical Claim Payments Auditing” procedure),來抽取樣本進行專業醫師審查,藉由樣本審查結果判斷費用給付方式。整個稽核流程以健保高屏分局個案進行資料模擬,以驗證理論之適用性。最後,估算成本模式,提高採用此稽核流程的可行性。
研究結果發現此稽核流程具有下列特點:1)抽樣數遠低於現行制度,大幅降低稽核人力成本與時間成本。2)流程中含激勵機制,可誘導醫療單位朝向合理申報,避免不合宜的醫療行為。3)因引用國際標準之抽樣計劃,極具公信力,可降低執推行阻力。
[關鍵詞]:全民健康保險、抽樣計劃、激勵機制
Abstract
National Health Insurance (NHI) has been implemented in Taiwan for nearly eight years; since then, over 96% of 23 million residents of Taiwan have benefited from this program, and 70% of them are satisfied. Recently, the growth rate of healthcare expenditure, however, has been phenomenally rapid, owing to the ageing population, the economic development, the expansion of health insurance, the increased supply of healthcare resources, and the innovation of medical technology. Under the circumstance that the bill of raising the insurance premium rate could not be passed by the legislative congress, the Bureau of NHI (BNHI) was forced to economize on expense to achieve the financial balance. Currently, the BNHI implements “total amount control” to control the total medical claimed payments of each medical healthcare provider. Facing the increasing volume of documentary auditing, the BNHI has to make its efforts on how to improve its auditing efficiency. This is also one of the purposes of this thesis.
This study aimed to establish a reasonable and fair auditing procedure of medical claim payment, termed “medical claim payments auditing (MCPA) procedure”. At the stage of professional auditing, adopted the “MIL-STD-105E sampling plan” to select data for professional audit and used the auditing results as a payment criterion. To verify the adaptability of the MCPA procedure, the researcher used the data provided by the institutes of Kaohsiung and Pintong as simulation objects. Further, the estimated cost model was adopted to increase the possibility of using this procedure.
The MCPA procedure consists of the following characteristics: 1) The number of sampling is much lower than that of the current system used by the NHI, thus the audit labor-force and time can be reduced significantly. 2) The incentive mechanism design encourages the healthcare providers to honestly apply their medical claim payments and avoids inappropriate healthcare services. 3) Adopting international standards of sampling technology makes the MCPA procedure trustworthy and simultaneously can reduce the implementing obstructs.
Keywords: National Health Insurance; Sampling plan; Incentive mechanism design
參考文獻
一、中文文獻
1.工業局中衛小組(1988)。免檢制度推動手冊。中衛管理叢書。
2.中央健保局高屏分局(1998)。住院醫療費用三抽一減量抽審作業辦法。
3.中央健保局高屏分局(1998)。醫學中心住院送核核付落後改善方案。
4.中眼會訊(2001)。總額預算支付制度座談會會議記錄。http:www.oph.org.tw
5.行政院衛生署中央健康保險局(2000)。全民健康保險醫事服務機構醫療服務審查辦法。
6.吳凱勳(1998)。全民健康保險醫療費用審查制度的檢討與改進。台北,中央健保局專案研討會。
7.呂欣潔:總額預算支付制度下區域分配之公平性及其最佳預算分配模式,國立高雄第一科技大學風險管理與保險研究所90年碩士論文,指導教授:許碩芬博士。
8.李玉君,八十九年九月,德國健康保險率之關係 ,國立臺灣大學公共衛生學院醫療機構管理研究所碩士論文。組織體制之探討,歐美研究,第三十卷第三期,pp41-88.
9.周麗芳、陳曾基(2000)。德國健康保險門診醫療費用支付審查制度。台灣醫界,43(2):49-55。
10.林峰立、蔡憲唐、江宏哲、鄭榮郎 (1998)。標準作業程序在醫療產業的應用-以中央健保局高屏分局為例。中山管理評論,6(4):1219-1232。new window
11.洪清福(1997)。醫療費用主要核減原因及因應之道。醫院,30(5):18-20。
12.洪碧蘭(1997)。支付標準現況與問題探討。醫院,30(6):22-27。
13.洪碧蘭、楊志良(1998)。健保支付與醫界生態關係之初探。醫院,31(6):41-60。
14.洪慧如(1997)。「全民健康保險審查實務初探」摘要之我見:醫院,30(6):16-21。
15.洪慧如(1998)。加拿大健康保險制度及其對我國的啟示。醫院,31(3):1-11。
16.韋端(1977),「可靠性、信賴性及定性抽樣法」,品質管制月刊14卷12期pp3-7。
17.韋端(1978),「可靠性、信賴性及定性抽樣法」,品質管制月刊15卷1期pp1-11。
18.韋端(1990),《抽樣方法之應用》,中國統計學報社,台北。
19.韋端、鄭光甫合著(1995),《抽樣方法-理論與實務》,,三民書局,台北。
20.馬培卿(1997)。德國健康保險制度及其對我國的啟示。醫院,31(1):21-28。
21.高資彬(1997)。專業審查核減原因及分析。醫院,30(5):11-17。
22.張溫溫(1996)。全民健康保險醫療費用審查制度。衛生報導,6(10):2-10。
23.張道義(2001)。德國健康保險法支付制度法律關係的分析。台大法學論叢,30(6):.227-263。
24.張道義(2000)。德國十九世紀社會福利國理論-Lorenz von Stein(1815-1890)的社會福利國。NSC 88-2414-H-001-005,行政院國家科學委員會。(己結案)
25.莊逸洲(1995)。全民健康保險醫療服務及費用審查方法。衛生署研究報告。
26.許南佳、林晉寬著(1993)。物料管理。台北:天一圖書公司。
27.許國文、陳柏瑞(1997)。某區域教學醫院住院支付項目及醫師核減率檔案分析及影響因素之探討。中央健康保險局委託研究計劃報告。
28.陳星助(1997)。全民健保各層級醫院醫療費用主要核減原因及因應之道。醫院,30(5):21-24。
29.黃月桂、許光宏(1998)。中央健保局住院醫療服務及專業審查之評估研究。中央健康保險局委託研究計劃報告。
30.黃肇明(1996)。全民健康保險醫療費用抽樣審查與回推制度。醫療資訊電腦化,17:12-16。
31.楊漢泉(1997)。全民健康保險醫療費用協定委員會工作與展望。醫院,30(5):55-56。
32.劉見祥(1997)。全民健康保險醫療費用支付標準修訂現況及未來展望。醫院,30(5):2-5。
33.劉見祥(1999)。全民健保支付制度之趨勢。醫院,32(6):15-20。
34.劉明勳(1998)。英國國民保健制度之改革及對我國之啟示。醫院,31(5):1-10。
35.劉彥秀(2001)。中國大陸醫療保險制度之現況。中央健康保險局企劃處。
36.劉漢容著(1996)。品質管制。台南:勝凱企管顧問公司。
37.蔡憲唐(1997)。中央健康保險局高屏分局ISO 9000 系列訓練及輔導報告。
38.蔡憲唐、江宏哲、李來錫、郭倉義 (1998)。健保組織員工績效評核之研究-以高屏分局為例。亞太經濟管理評論,2(1):81-95。new window
39.蔡憲唐、葉惠忠、江宏哲、林清維 (1999)。住院醫療費用審查ABC三級分案作業。醫院,32(6):62-71。
40.鄭明智(1995)。簡介全民健保之醫療審查制度與醫院之對策。醫院,28(2):17-32。
41.盧瑞芬、謝啟瑞(2000)。醫療經濟學。台北:學富文化事業有限公司。
42.醫審審查計畫(2001)。對於醫療服務審查的構思。中央健康保險局醫審小組審查計畫組。
43.顧培華(1998)。健保局台北分局特約醫院預審現況及其與門診醫療費用核減。

二、英文文獻
1.Anderson GF, Hussey PS. Population aging: a comparison among industrialized countries. Health Affair 2000; 19 (3): 191–203.
2.Bishai, D.M. and H.C. Lange(2000), The willingness to pay for wait reduction: the disutility of queues for cataract surgery in Canada, Denmark, and Spain. Journal of Health Economics, 19,219-230.
3.Bureau of National Health Insurance Website (2004). htt://www.nhi.gov.tw.
4.Busse R, Wismar M. Health target programmes and health care services—any link?:A conceptual and comparative study (part 1). Health policy 2002; 59(3):209-221.
5.Cheng TM. Taiwan''s new national health insurance program: Genesis and experience so far. Health Affair2003; 22(3):61-76.
6.Chiang TL. Taiwan’s 1995 health care reform. Health policy 1997; 39(3):225-239
7.Denton FT, Gafni A, Spencer BG. Exploring the effects of population change on the costs of physician services. Journal of Health Economics 2002; 21(5): 781-803.
8.Denton FT, Spencer BG. Population aging and its economic costs: a survey of the issues and evidence. Canadian Journal on Aging 2000; 19 (1): 1–31.

9.Duncan AJ. Quality Control and Industrial Statistics, 5th ed., McGraw Hill Press; 1994.
10.Duncan, A.J. (1986), Quality Control and Industrial Statistics, McGraw Hill.
11.Getzen TE. Health care is an individual necessity and a national luxury: applying multilevel decision models to the analysis of health care expenditures. Journal of Health Economics 2000; 19:259-270.
12.Grant and Leavenworth (1988), Statistical Quality Control, McGraw Hill.
13.Hussey P, Anderson GF. A comparison of single- and multi-payer health insurance systems and options for reform. Health policy 2003;66 (3):215– 228.
14.Juran and Gryna (1993), Quality planning and Analysis, McGraw Hill.
15.Juran JM, Gryna FM. Quality planning and Analysis, 3th ed., McGraw Hill Press;1993.
16.Lanata CF, Black RE. Lot quality assurance sampling techniques in health surveys in developing countries: advantages and current constraints. World Health Stat Q 1991; 44(3):133-139.
17.Lemeshow S, Taber S. Lot quality assurance sampling: single and double sampling plans. World Health Stat Q1991;44(3):115-132.
18.Lu JF, William CH. Does universal health insurance make health care unaffordable? Lessons from Taiwan. Health Affair 2003; 22(3):77-88.
19.Mitra, A.(1993), Fundamentals of Quality Control and Improvement, Macmillian.
20.Montgomery DC. Introduction to Statistical Quality Control, 4th ed., Wiley Press; 2000.
21.Montgomery, D.C (1991), Introduction to Statistical Quality Control, Wiley.
22.Moskowitz, H. and H. T. Tsai (1988).A One-Sided Double Screening Procedure Using Individual Unit Misclassification Error. Management Science, 34, 9:1139-1153.
23.Moskowitz, H., R. Plante and H.T. Tsai (1993).A Multistage Screening Model for Evaluation and Control of Misclassification Error in the Detection of Hypertension. Management Science, 39:307-321.
24.Naohiro Yashiro. Aging of the population in Japan and its implications to the other Asian countries. Journal of Asian Economics 1997; 8(2): 245-61
25.OECD(1994), The reform of health care systems: a review of seventeen OECD countries, Paris: OECD.
26.Owen, D.B., D. McIntire and E. Seymour(1975).Tables using one or two screening variables to increase acceptable product under one-sided specification. Journal of Quality Technology, 7, 3:127-138.
27.Phelps, C.E.(1997), Health Economics, new York, NY: Addison-Wesley Educational Publishers Inc.
28.Ryan, T.P.(1989), Statistical Methods for Quality Improvement, Wiley.
29.Taylor, H.C. and J.T. Russel(1939).The relationship of validity coefficients to the practical effectiveness of tests in selection: Discussion and tables. Journal of Applied Psychology, 23:565-578.
30.Valadez JJ, Brown LD, Vargas WV, Morley D. Using lot quality assurance sampling to assess measurements for growth monitoring in a developing country''s primary health care system. Int J Epidemiol1996; 25(2):381-387.
31.Wadworth, Stephen and Godfrey(1986), Modern Methods for Quality Control and Improvement, John Wiley.
32.Weber RT. An Easy Approach to Acceptance Sampling: How to Use MIL-Std-105E, 1th ed., American Society for Quality Press; 1991.
 
 
 
 
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