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題名：中老年人的健康行為、健康與醫療利用之實證分析
作者：陳芝嘉
作者(外文)：Chih-Chia Chen
校院名稱：國立東華大學
系所名稱：經濟學系
指導教授：林慧菁
余清祥
蔡偉德
學位類別：博士
出版日期：2014
主題關鍵詞：健康危害行為；存活分析；921震災；死亡風險；健保資料庫；老人醫療利用；醫療需求價格彈性；就醫免部分負擔；非線性差異中之差異估計模型；unhealthy behavior；survival analysis；921 earthquake；mortality risk；NHI database；medical care utilization of elderly；price elasticity of medical care demand；copayment exemption；nonlinear difference-in-difference
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本研究分別探討中老年人健康行為、健康與醫療利用的三個議題，研究目的是了解中老年人的健康與醫療利用特性，資料來源為臺灣地區老人保健及生活問題調查資料以及1998年至2004年全民健康保險資料庫，研究結果分述如下：
第一個議題、探討健康危害行為對中老年人健康與壽命的影響。吸菸、喝酒與嚼檳榔的不良嗜好對健康造成的危害，多半在中老年後陸續罹患慢性病或重大疾病（例如：癌症、肺炎、肝炎、口腔疾病等），往往被歸因於老化而忽略預防的重要性，本文使用臺灣地區老人保健及生活問題調查資料驗證上述推論。結果顯示：目前吸菸的老人死亡危險率最高，及早戒菸或長時間的戒菸有較低的死亡率，但若無法持續戒菸則無益於降低死亡風險。此外，戒酒者的死亡風險明顯高過不喝酒者，顯示戒酒者往往是罹患重症或自覺健康狀況變差才選擇戒酒，而嚼檳榔亦會增加死亡風險。根據本文研究推論，長期不良健康嗜好（吸菸、喝酒、嚼檳榔）對身體造成的損傷會隨著年齡增長而累積，增加老年時期疾病的發生機率以及死亡風險。
第二個議題、921震災對中老年人死亡風險的影響。有別於其他相關研究，本文的研究焦點是將災區區分為領有震災卡的災民與災區其他非災民，分析在震災中受創嚴重程度不同之民眾，震災後一段期間死亡風險的影響，資料來源為1998年至2004年全民健保資料庫。研究發現：震災在短時間內造成災區嚴重的死傷，災區民眾的死亡風險皆顯著高過非災區民眾，並且災區領有震災卡之災民的死亡風險的影響效果不會在短時間內消失，而是會持續近一年時間。
第三個議題、老年人醫療利用的價格效果。利用民國88年921震災後，將政府對災民發放921震災卡之免部分負擔的優惠視為一自然實驗，將差異中之差異分析方法應用於非線性模型（負二項分配迴歸模型及二部模型），分析65歲以上老人之健保醫療利用的價格彈性。在控制時間趨勢與族群差異後，本文研究發現：921震災健保卡之價格補貼顯著提升災民的門診醫療利用3.68次（男性樣本則為4.70次），門診價格彈性為-0.06（男性樣本為-0.07），但對住院醫療利用卻無明顯地影響，在控制價格補貼的處置效果下，震災傷害提高老人門診醫療利用5.21次（男性樣本為5.02次）。此外，雖然老年人因生理機能退化，醫療利用多於年輕族群，價格彈性原先就不高，但本文的研究發現：在控制震災處置效果之下，老年人在不同醫事機構層級的醫療利用價格彈性有明顯差異，老年人在區域醫院級的門診價格彈性為-0.13（男性樣本-0.14），明顯高過基層院所的門診價格彈性-0.06（男性樣本-0.07），顯示921震災卡價格補貼有提升老年人到大醫院就醫的動機。不同疾病別的醫療利用價格彈性亦有些許不同，輕微疾病如感官系統疾病與皮膚疾病的價格彈性偏高，其中感官系統疾病的價格彈性為-0.08（男性樣本為-0.10），皮膚疾病的價格彈性為-0.07（男性樣本為-0.09），皆明顯高過所有門診價格彈性-0.06（男性樣本為-0.07）；反之，較為嚴重的疾病如心血管疾病與消化系統疾病的價格彈性則偏低，顯示震災卡使民眾小病多就診的傾向。
The study discussed issues regarding the health behavior of the middle age and elderly, and their health and medical use as well. The study goal is to understand the health and medical use features of the middle age and the elderly with data from the Taiwan Survey of Health Care & Living Status of the elderly and the National Health Insurance database between 1998 and 2004.
The first goal is to discuss the effect of unhealthy behavior to the health and life for the middle age and elderly. The harms like chronic diseases or severe diseases (e.g.: cancer, pneumonia, hepatitis, oral diseases etc.) arising from bad habits to health, such as smoking, drinking and chewing beetle nut, would appear successively in the middle age and elderly. Meanwhile, they are usually attributed to aging and therefore the importance of earlier precaution is ignored. We used the data from Taiwan Survey of Health Care & Living Status of the Elderly to confirm the preceding conjectures. The results show that the smoking elderly has the highest mortality rates, and those who quit smoking earlier ages or quit smoking for a long period of time have lower mortality rates. However, lower mortality rates do not appear in the group without continuous abstinence. In addition, the mortality risk of abstainers is obviously higher than those do not drink. It shows that the abstainers usually would not quit drinking until they have severe disease or feel deteriorated health conditions. Meanwhile, chewing beetle nut would also increase the mortality risk. In short, bad habits (smoking, drinking, and chewing beetle nut) would accumulate the damage to health and increase the possibility of falling in disease and the mortality risk of elderly.
The second study object was the effect of 921 earthquake to the mortality risk of middle age and elderly, using the NHI database from 1998 to 2004. Different from previous studies, one of the key features of this study was to distinguish the mortality risks between the victims with earthquake card and those without the cards. The major findings include the earthquake caused severe casualties within short period of time, and the mortality rates of people in the disaster area are significantly higher than those not in the disaster area. In addition, the earthquake effect to mortality risk would not disappear suddenly but last almost for one whole year.
The third study goal is to explore the price effect of medical use of the elderly. The copayment exemption offered by the government to 921 earthquake victims was adopted in the experiment. The variance analysis method was applied to the non-linear model (Negative Binomial Regression Model and two part model) for the analysis of price elasticity in term of NHI used by elderly aged over 65, after controlling the time trend and group variance. We found that the subsidy of copayment exemption to earthquake victims obviously increased the use of outpatient service at the scale of 3.68 times (4.70 times for male samples), with outpatient service price elasticity -0.06 (-0.07 for male samples). However, it did not significantly affect the inpatient visits. With controlled treatment effect of subsidy, the earthquake had increased the use of elderly outpatient services for 5.21 times (5.02 times for male samples). In addition, although the elderly are believed to have lower price elasticity, we found that the price elasticity of elderly can be significantly different, depending on which types of hospitals thet visited. The outpatient price elasticity of elderly using regional hospitals was -0.13 (-0.14 for male samples), which was obviously higher than the outpatient price elasticity of elderly using basic hospitals -0.06 (-0.07 for male samples). It shows that 921 earthquake card subsidy may increase the motivation of elderly to big hospitals for treatment. The price elasticity of medical services is also related to disease patterns. The price elasticity of mild diseases, such as sensational system and skin disease, was relatively high. The price elasticity of sensational system was -0.08 (-0.10 for male samples), and that of skin disease was -0.07 (-0.09 for male samples), both significantly higher than the average outpatient price elasticity -0.06 (-0.07 for male samples). On the contrary, the price elasticity of severe diseases, such as cardiovascular disease or digestive system was relatively low. This suggests that issuing the earthquake card may cause waste of medical resources by incurring possibly unnecessary hospital visits for those with minor illness.
第二章 健康危害行為對健康與壽命的影響-以男性中老年人為例
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第三章 921震災對中老年人死亡風險的影響
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