臺灣博碩士論文加值系統

職業災害事涉勞工生命的健康安全，本質上不僅是一項健康事件（health matter），更攸關企業生產效能及國家經濟的永續發展。由於社會資源的有限，透過精確合理的成本估算，將可提供符合學理及實證結果的建議，做為擬定職業安全衛生防災策略、決定介入方案優先順序、精算職災保險費率與給付以及計畫成效評估的參考。
依職災所造成之衝擊，一般可以分為社會成本、企業雇主成本與勞工個人成本；而以經濟損失的觀點，根據其定義與分類，又可區分為直接損失、間接損失與福利損失。其所造成之損失與影響，對勞工、企業雇主與社會整體分別有以下之項目：
1. 勞工方面：家庭生產力與收入損失、心理傷痛、醫療或喪葬等額外支出費用。
2. 雇主方面：法律糾紛、民事或道義補償、機械器具與原料損壞、商譽與收益損失、行政處分。
3. 社會方面：社會救助與福利支出、醫療給付、死亡殘廢者保險給付或年金支出。
而依職災損失的分類，直接、間接與福利損失，分別代表以下的項目：
1. 直接損失：勞工、雇主與社會的醫療成本、雇主財貨損失及保險費用的增加。
2.間接損失：包括暫時或永久失能的勞工未來生產能力損失（productivity losses），亦即罹病成本（morbidity cost）與死亡成本（mortality cost）。
3.福利經濟損失：社會福利支出、勞工個人與家人之身體疼痛pain）、精神傷痛（suffering）與休閒生活損失(amenity)。
另外依職業災害對勞工個人造成的健康衝擊（health impact）與後果（consequence），可分為死亡（mortality）、永久全失能（permanent totally disability, PTD）、永久部份失能（permanent partly disability, PPD）、暫時全失能（temporary totally disability, TTD）及暫時部份失能（temporary partly disability, TPD）。其中，死亡、永久全失能及永久部份失能對勞工所造成的傷害屬於不可恢復的（irreversible）；雖然發生的比例相對於暫時失能的案例較少，但產生的後果不論對個人、家庭、雇主及社會最為嚴重。因此，一般政府職業災害預防計畫，多設定以減少此一災害的發生為目標。本計畫亦主要以此類型職災，定義為嚴重職業災害（serious occupational injuries）類型，估算其潛在損失人年及殘廢勞工疼痛貨幣價值。
上述不同項目之成本，顯示職災成本涵括層面的廣泛，甚至牽涉到非市場產品（non-market goods）的intangible cost價值衡量，例如：疼痛與精神傷痛。目前經濟學者已經從評價衛生政策有關的健康經濟學（health economics）與福利政策的觀點，發展經濟理論模型與方法，加以探討不同層面意外事故經濟成本的測量，與預防性介入方案的評估。例如：疾病成本法（cost of illness）與假設性市場評價法（contingent valuation method）。此外，從職業災害發生的類型與安全衛生管理的角度，已有許多估算社會成本與企業雇主損失的推估模式，例如：Henrich的冰山理論以及Bird的三角比例理論，分別估算直接/間接損失以及不同事故嚴重程度之比例。
由於不同的影響層面有不同的成本項目考量；而且職業災害的成因與結果必然影響成本的測量。表二係整理目前衡量職業災害衝擊有關之指標，各指標各有其內涵及假設差異，雖然美國、英國、澳洲等國家應用不同指標，定期系統性地評估整個國家職業災害的衝擊，但是其指標並不一致，因此難以直接比較。最常見於公部門發表的指標，除了一般個案計數值（case counts）外，最常見的是調整年齡別、性別的發生率（含morbidity rate及mortality rate），以及潛在人年損失(years of potential life lost)。由於以發生率為指標的結果，對於老年人的計算與年輕人相同，對於職業災害較強調生產力損失的精神有所差異；因此，部份近期發表的衡量災害衝擊的研究，如：Segui-Gomez的回顧性研究指出，以潛在人年損失(years of potential life lost, YPLL)及貨幣單位估算出來的成本，仍然是目前估算有關傷害（injuries）衝擊的有力計量單位（powerful metric）。另外，Nurminen亦強調基於人年損失的計量已足夠應用於職業安全衛生領域的政策擬定及介入方案排序。 雖然，現有健康相關經濟評估方法，大致可分為成本分析（cost analysis）、成本有效性分析（cost-effectiveness analysis, CEA）、成本效用分析（cost-utility analysis, CUA）及成本利益分析（cost-benefit analysis, CBA）。不論採取何種評估方法，前提是必須先估算職業傷害的成本及潛在衝擊。
我國在過去有良好的經濟發展，但也發生許多職業災害而導致鉅大的社會成本。根據勞工保險局現金給付資料，我國因為職業傷害（occupational injury）導致死亡的勞工人數（扣除外勞），以五年為一時段來看，已經呈現逐年下降的趨勢；死亡人數從1986-1990年間每年平均1,580人，至1991-1995年每年1,321人，再下降至1996-2000年的年平均1,089人。然而，請領殘廢給付的勞工人數，卻沒有相同的趨勢；同時段從1986-1990年間每年平均6,049件，雖然進步至1991-1995年每年4,874件，然而1996-2000年又上升至每年5,249件。同時由勞委會勞工檢查年報數據，相較於美國、英國、日本等工業先進國家，我國的職災發生率約是這些國家的5-10倍；這些數值背後代表我國社會、企業雇主與勞工個人及家庭，仍面臨著職業災害所造成的鉅大成本損失。職業災害的預防仍然是影響我國經濟發展、社會公義及安和樂利的重要議題。
目前，我國勞保殘廢及死亡的給付即將改成年金制（annuity pension）。然而，對於給付標準的估算仍然有很大的爭議；最主要有幾個問題，包括：不知殘廢勞工真正的存活以及如何估算正確的損失人年，從而給予應有的給付；另外，只看殘廢嚴重程度，而不管其他變因如：災害類型的給付標準，是否真正合乎公平與效率，還存有疑義欠缺一致共識，且缺乏實證資料。此外，在與非職業傷害的健康事件，例如：癌症、糖尿病、愛滋病及肝炎等疾病，也因為缺乏共同的比較單位，政府難以建立理性客觀的資源分配及防治成效評量基礎。
本研究主要的目的，希望能估算出嚴重職業災害的事件，包括：終身殘廢及死亡的個案所造成的潛在人力損失，進而分析不同災害類型，例如：墜落、感電、夾捲切割的人年損失。此外，我們也將分析不同殘廢程度勞工的潛在人年損失，應用估算成果評估勞保嚴重職災改為年金制以後，預期可能的社會財務負擔。同時，對於職災所引起的福利損失，應用假設性市場評價法(contingent valuation method, CVM)估算非市場貨財的良好特性，嘗試予以量化其貨幣成本。如此，將有助於了解我國職業災害預防實際的效益，為後續職災防治的政策評估及介入方案擬定，提供良好的參考基準。
本研究的第一部份，以台灣81,249名請領殘廢給付勞工及20,001名請領死亡給付勞工的潛在人年損失(YPLL)及潛在工作人年損失(YPWLL)，並分析在不同災害類型的分佈差異。運用Monte-Carlo 推估方法估算罹災後的平均存活餘命（life expectancy after injury）並與一般國民比較，估算出終生預期生命損失。結果發現，不同災害類型平均生命損失並不相同，介於7.4-13.6年之間。殘廢所造成的終生潛在人年損失大約與死亡的損失相同；但潛在工作人年損失，亦即65歲退休前具生產力之年數損失，則殘廢者約為死亡者的62%。研究建議，基於我國過去15年的經驗，部份災害類型如：墜落、感電較容易造成死亡的個案，部份災害類型如：夾捲切割多造成殘廢後果。因此，應該同時考量死亡及殘廢做為政策擬定的依據，而利用Monte-Carlo估算之潛在人年損失，具有良好的準確度，可以做為我國及其他新興工業國家未來衡量職業災害社會衝擊的參考。
本研究第二部分，進一步估算我國勞保15等級分類標準下，每一等級的存活及平均人年損失。由於其結果呈現poor to fair的一致性，可以預期除了殘廢等級外，還有其他unobserved heterogeneity存在。經由Cox model及加速時間模型之Weibull分布假設，發現除年齡、性別外，殘廢等級、失能部位、災害類型以及投保薪資都是影響罹災者受傷後存活的變因。以殘廢等級來區分，殘廢者平均餘命損失介於9-19歲；失能部位發生於神經系統、胸腔、腹部等人體重要部位以及下肢，前三級永久完全失能，交通事故、倒塌、跌倒及移動中物體撞擊以及較低的投保薪資，顯著有較低的存活。研究建議，我國未來殘廢年金應優先照顧重殘之完全失能者，第四等以後之部份失能者應協助解決其重建、就業面臨的問題。由於災害預防主要以災害類型加以區分，研究結果對於未來擬定職災預防計畫之優先順序，亦提供具參考性之訊息。
本研究第三部分，係利用假設性市場評價法（CVM）來估算殘廢者罹災後疼痛的貨幣價值。透過一種假設性無副作用的止痛藥可完全止痛且藥效持續24小時，以逐步競價方式詢問罹災者在費用許可下，最大願付金額。結果顯示，家庭收入、較高年齡、墜落災害、住院時間長及購買天數大於一天者，願付金額顯著性較高。另外，受傷後醫療支出較高者，發生時間超過兩年的罹災者，有較低的願付金額。不同的Weibull及lognormal分佈模型下，分別得到一天1,913及1,791元的最大願付價值。本研究結果符合一般經濟假設，其數據在於具體呈現未來每減少一件殘廢職災，至少可多增加計入疼痛所衍生的貨幣價值；此外，勞工受傷後因疼痛衍生之貨幣成本亦可透過本研究得到一個參考值，如果未來勞工保險福利支出願意涵括此損失，則其補償基準亦可參考本研究之結果。

The thesis was comprised of three papers. In the first paper, we assessed the life expectancy lost and potential work life lost resulting from cases of mortality and permanent disability by different types of occupational injuries during 1986-2000 in Taiwan. Databases of occupational mortality and permanent disability during 1986-2000 were retrieved from the Bureau of Labor Insurance, which were linked with the database of national death registry to construct the survival function. Then, a Monte Carlo simulation method was used to extrapolate the survivors up to 600 months to derive the life expectancy for different injury cases with permanent disability (n=81,249). For the mortality cases (n=20,001), the life expectancy lost were estimated by gender-, age-matched based on the life table of each calendar year. For occupational permanent disability, different types of injury showed variations of YPLL (years of potential life lost) ranged from 13.6 years to 7.4 years per case. The overall YPLL of occupational permanent disability is almost the same as that of occupational mortality, with a ratio of 1.04:1. After accounting for permanent impairment of working ability and assuming a uniform retirement age of 65, the YPWLL (years of potential work life lost) due to occupational permanent disability is about 62% of that resulting from occupational mortality. We concluded that permanent disability resulting from occupational injuries has a significant impact on society. Our estimations can provide empirical basis for both the health policy decision and improvement of the equity and efficiency of workmen compensation system in Taiwan and possibly other newly developed countries.
In the second paper, the objectives of the study are to estimate the life expectancy and exploring the determinants of survival for workers with occupational permanent disability. Databases of occupational permanent disability during 1986-2000 were retrieved from the Bureau of Labor Insurance and linked with the database of national death registry to construct the survival function. A Monte Carlo simulation method was used to extrapolate the survivors of up to 600 months to derive the life expectancy for different types of occupational injuries with permanent disability (n=81,249). The Cox (proportional hazards) regression was conducted to explore the determinants and estimate the hazard ratios. We included demographic variables including age, gender, insured wage, severity of disability, injury causes, and organ-system disability into the model as the covariates. The results showed that workers with occupational permanent disability survived shorter than the general population after injury, giving estimated years of life loss ranged from 9 to 19 years. After the adjustment of age and gender, we found that a higher severity of disability, impairment of vital organ or lower extremities, and a lower insured wage were significantly associated with shorter survival. Injury types of struck by sliding objects, transportation, trip/slip, and tumble down showed hazard ratios between 1.24 – 1.34 compared with injury by caught in. We concluded that workers with occupational permanent disability survived shorter than general population. Our findings identified major determinants to predict survival for workers with occupational permanent disability, which may be used to improve the equity for workmen compensation system.
Finally, within the process of calculating the true costs of illness, physical pain is a component of intangible, or human, costs. One method of estimating the monetary value of such costs is the ‘contingent valuation method’ (CVM), a stated preference method based upon the elicitation of levels of willingness to pay (WTP) facilitated through surveys. This study is amongst the first of its kind to apply CVM to the estimation of the cost of the removal of physical pain resulting from permanently-disabling occupational injuries. We assume that a painkilling drug has been invented to mitigate physical pain with the advantages of validity and instantaneity, and without any side effects. The WTP of each of the respondents is determined by a two-step sequential-bidding process. The maximum WTP under log normal distribution was NT$1,791/day (US$ 65.1), whilst under Weibull distribution it was NT$1,913/day (US$ 69.6). Older respondents, those with higher household income, fall injuries, longer periods of hospitalization, or with a perceived demand for the painkilling drug in excess of one day, displayed a positive independent effect on the eliciting of their WTP. In addition, respondents with higher ‘out of pocket’ expenses, or where the interview took place two years or more after the injury occurred, responded with a lower WTP.

TABLE OF CONTENTS i
LIST OF TABLES iv
ACKNOWLEDGEMENT vi
CHINESE ABSTRACT vii
ABSTRACT xiv
CHAPTER 1
INTRODUCTION
1.1 Classifications of economic costs of health 1
1.2 Calculation of economic costs 4
1.2.1 Cost of illness method 4
1.2.2 Willingness To Pay method 5
1.3 Types of economic evaluation 7
1.3.1 Cost-benefit analysis 7
1.3.2 Cost-effectiveness analysis 8
1.3.3 Cost-utility analysis 8
1.4 Measuring the health impact of injuries 9
1.4.1 A brief review of health metrics 9
1.4.2 Years of potential life lost 12
1.5 Overall research objectives 14
CHAPTER 2
HEALTH IMPACTS RESULTING FROM DIFFERENT TYPES OF SERIOUS OCCUPATIONAL INJURIES IN TAIWAN
2.1 Introduction 16
2.2 Study subjects 18
2.2.1 Measures 20
2.3 Results 22
2.4 Discussion 24
2.4.1 Validity of the estimation based on Monte Carlo extrapolation method 25
2.4.2 Policy implication of this study on occupational safety and health 27
2.5 Tables and figure 30
CHAPTER 3
LIFE EXPECTANCY ESTIMATIONS AND THE DETERMINANTS OF SURVIVAL ON WORKERS WITH PERMANENT OCCUPATIONAL DISABILITIES
3.1 Introduction 34
3.2 Study population and methods 36
3.2.1 Study population 36
3.2.2 Disability and injury characteristics 36
3.2.3 Survival analysis and estimation of life expectancy lost 37
3.3 Results 39
3.3.1 Characteristics of subjects 39
3.3.2 Estimation of life expectancy and potential years of life lost 39
3.3.3 Determinants of survival for workers with occupational permanent disability 40
3.4 Discussion 41
3.4.1 Validity of the estimation based on Monte Carlo extrapolation method 42
3.4.2 Implication of the determinants of survival 42
3.4.3 Limitations of this study 44
3.4.4 Implication of the results 45
3.5 Tables 47
CHAPTER 4
STATED PREFERENCES FOR THE REMOVAL OF PHYSICAL PAIN RESULTING FROM PERMANENTLY-DISABLING OCCUPATIONAL INJURIES
4.1 Introduction 51
4.2 Subjects 54
4.3 Empirical methods and results 58
4.4 Discussion 63
4.5 Conclusions 68
4.6 Notes 69
4.7 Tables 73
CHAPTER 5
DIRECTIONS FOR FUTURE RESEARCH WORK
5.1 Studies on evaluation of economic impacts 77
5.2 Studies for policy implication on compensation 78
BIBLIOGRAPHY 79
APPENDIX
Appendix A: Scenario for Eliciting WTP in the Contingent Valuation Question 89
Appendix B: Procedure of sequent-bid among five different star 91
Appendix C: The long-term distribution of YPWLL resulting from different types of injury by different consequences 92
Appendix D: Supplement Tables 94

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