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研究生:吳汶娟
研究生(外文):Wen-Chuan Wu
論文名稱:原住民與非原住民家戶自付醫療費用之研究
論文名稱(外文):A Study on Out-Of-Pocket Health Care Expenditure of Aboriginal and Non-aboriginal households in Taiwan
指導教授:李玉春李玉春引用關係
指導教授(外文):Yue-Chune Lee
學位類別:碩士
校院名稱:國立陽明大學
系所名稱:衛生福利研究所
學門:醫藥衛生學門
學類:公共衛生學類
論文種類:學術論文
論文出版年:2009
畢業學年度:97
語文別:中文
論文頁數:147
中文關鍵詞:原住民家戶自付醫療費用家戶自付醫療費用負擔
外文關鍵詞:ethnicityaboriginalhousehold out-of-pocket expenditure (OOP)ousehold out-of-pocket expenditure burden
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原住民的健康相關議題一直是各國衛生政策焦點,我國2020健康白皮書計畫亦將原住民族群列為計畫目標人口群之一。相關研究指出家戶自付醫療費用過高時對中低收入家庭有較大的經濟壓力。原住民家庭在社會中經濟弱勢之問題較其他族群更為嚴重,國外研究發現白人會比少數族群有較高的醫療費用及負擔。目前尚無國內研究探討原住民與非原住民家戶自付醫療費用之差異,故本研究目的在比較原住民與非原住民家戶自付醫療費用與負擔之差異。另外也探討居住地區都市化程度及醫療資源對家戶自付醫療費用之影響。
本研究為橫斷性研究,使用次級資料分析,採用Andersen Model中以家庭為單位之第一代醫療服務利用模式並加入第二代醫療利用模式中,由於自付醫療費用分析易受家戶醫療服務使用情形有無之影響,故使用Two-Part Model做分析。因受限於原住民家戶樣本數不足,為增加研究之統計效力結合92~95年四年之資料,並使用四年物價指數做校正,主要運用主計處家庭收支調查資料庫,串連戶籍檔以取得原住民之身分資料,由於主計處之調查缺乏健康之資料,為補足Andersen架構之需要因素,乃串連健保資料庫取得家戶重大傷病及共病指數資料,在醫療資源部分則串聯92~95年台灣地區醫療資源現況資料。本研究欲探討之依變項為家戶自付醫療費用(西醫、中醫、牙醫、住院、藥品、醫療用具設備器材、醫療保健用品及總費用)、家戶自付醫療費用負擔(總費用負擔—指佔可支配所得比例,並依負擔比例高低分為高度負擔(一)、高度負擔(二))。自變項為族群(原住民戶、戶長為原住民之原住民家戶(一)、戶長為非原住民之原住民家戶(二))、醫療資源、都市化程度,控制變項則有傾向因素-家庭組成(兒童比例、老人比例、戶口數)、經濟戶長特性(性別、婚姻狀況、教育程度、職業、保險身份別);能用因素-都市化程度、家戶可支配所得;需要因素-家中人口重大傷病比率、家中平均每人共病指數(依據Romano等人修訂之Charlson Comorbidity Index)。利用SAS9.2套裝軟體做資料分析,使用卡方檢定、ANOVA檢定進行描述性與雙變項分析,以廣義估計方程式(GEE)控制地區效應後分析自變項與依變項之關連性。
研究結果如下:
1. 自付醫療費用顯著因族群而異:在醫療服務利用部份,除了西醫外,家庭醫療服務利用皆會因族群而異。醫療自付費用部份,除了西醫門診、中醫門診、住院外,家庭自付醫療費用皆顯著因族群而異。
2. 自付醫療費用負擔顯著因族群而異。
3. 除了西醫門診、住院、總費用外,族群對自付醫療費用之影響顯著因醫療資源而異。
4. 除了西醫門診、中醫門診、牙醫門診、住院自付費用外,族群對自付醫療費用之影響顯著因都市化程度而異。
另外,也發現戶長為不同戶籍別之家戶在不同類別的利用與費用上會有顯著不同的結果。西醫門診、住院自付費用是較具公平性的,較不易受族群差異和醫療資源與都市化程度之影響。而中醫、牙醫門診自付費用之族群差異會因醫療資源的分布而異;在自付費用彈性較高的藥品、醫療用具設備器材及醫療保健用品,其族群差異則因都市化程度不同而異。
本研究結果可作為主管機關發展相關政策,以去除家戶自付醫療費用族群差異之參考。本研究發現原住民的醫療服務使用情形仍較低,但因利用未必接為必要,未來可深入探討經濟因子是否造成必要服務使用之障礙,另外,牙醫費用存在著族群與醫療資源的不平等,應促進牙醫資源分布均勻。未來研究建議可朝向Andersen model第四代之研究,以考量環境對不同族群自付醫療費用影響的動態模式。並可針對社會福利補助政策做探討,以了解社會福利補助政策的效益,另外,可進一步探討族群自付醫療費用負擔之公平性研究。

關鍵字:原住民、家戶自付醫療費用、家戶自付醫療費用負擔
The health of the aboriginal, for years, has always been one of the major policy issues in many countries. The “2010 White Paper for Healthy” has also listed the aboriginal as the target population. Research showed that for low-income family, the financial pressure increases significantly as household has higher medical expenditure. The aborigines are economically disadvantaged; researches in other countries found that the white have experienced higher health expenditures. Yet until now there is no study explores the difference in health expenditure between aboriginal and non-aboriginal family in Taiwan. Therefore the objective of this research is to compare the difference in health related out-of-pocket (OOP) expenditures and burden among aboriginal and non-aboriginal (ethnicity) household; with particular emphases on the interaction between ethnicity and degree of urbanization and distribution of medical care resources.
This study is a cross-sectional study which applied secondary data analysis, based on first generation Andersen model and the analyses of Survey of Family Income and Expenditure (SFIE) conducted by the Directorate-General of Budget Accounting and Statistics (DGBAS). The Office of Statistics of the Department of Health help us to link SFIE with Household Registry Database, NHI Claim data, and Area Medical Resources Profiles to obtained the information of aboriginal status, catastrophic illness, Co-morbidity Index, and amount of medical care resource. To include more aboriginals, we combined the data from 2001 to 2004 to increase the statistical power (expenditures were adjusted by Consumers’ Price Index). Besides, we applied Two-Part Model to account for that some households may have no health care utilization at all. Our dependent variables are total and different types of household OOP expenditure (Western outpatient care, Chinese medicine, dental care, hospitalization, medicine products/ materials/ equipment, health goods) and household OOP expenditure burden (percentage of household disposable income spent on OOP, household with high burden was defined as those with the burden index greater than or equal to 5% or 10%. Independent variables were ethnicity, divided into three groups: non-aboriginal household, aboriginal household with aboriginal head, and without aboriginal head), medical resources, urbanization, control variable were predisposing factors - family composition (proportion of children, elderly, size of the household), characteristic of household head(sex, marital status, education level, occupation, insurance status); enabling factors (urbanization, disposable income) and need factors (percentage who have catastrophic illness, household average Charlson’s Co-morbidity Index). Generalized Estimating Equation model (GEE) were conducted by SAS 9.2 software to the regional cluster effect into consideration..
Major results were as follows:
1. OOP were significantly associated with ethnicity; In addition to western outpatient visit, all types of household medical care utilizations were significantly different among different ethnicity groups. For OOP, besides western outpatient visit, Chinese medicine, and hospitalization, OOP were also significant associated with ethnicity.
2. Household OOP burden was also significantly associated with ethnicity.
3. In addition to western outpatient visit and hospitalization, the association between ethnicity and OOP were significantly different among region with different amounts of medical resources.
4. Besides western outpatient visits, Chinese medicine, dentistry, and hospitalization, the association of household OOP and ethnicity varied among regions with different level of urbanization.
5. OOP varied significantly different between aboriginal family with and without household head.
6. Impact of interaction of ethnicity and medical resources/ urbanization on OOP were not significant in western outpatient visit and hospitalizations; whereas the interaction effects of ethnicity and medical resources on OOP were significant in Chinese medicine, and dentistry. Besides the interaction effects of ethnicity and urbanization on OOP were also significant in OOP of medicine products, medical material equipment, and healthcare goods which are more likely to be affected by price.
These results can be considered when developing related policy to eliminate the difference in ethnicity difference in OOP. However, because the uses of health care resources are not necessarily essential, future study may further explore whether there are financial barriers for the essential healthcare. Besides, because the distribution of OOP was less equitable in dentistry OOP among ethnicity group and interaction of ethnicity and medical resources; policy may be developed in the future to enhance more equitable distribution of dental care
Future study may apply the dynamic fourth generation of Andersen model to explain the dynamic relationship between OOP, ethnicity, and interaction of ethnicity and environment; and to evaluate whether social welfare subsidy policy may have impact on reduction of ethnicity disparity on household OOP.

Key words: ethnicity, aboriginal, household out-of-pocket expenditure (OOP), household out-of-pocket expenditure burden
誌 謝 ……………………………………………………………I
中文摘要 ..............................................III
Abstract ……………………………………………………………V
目錄 ………………………………………………………..VIII
圖、表及附錄目錄 X
第一章 緣起 1
第一節 研究背景與動機 1
第二節 研究目的及問題 3
第三節 研究之重要性 4
第四節 重要名詞定義 4
第二章 文獻探討 6
第一節 台灣原住民背景介紹 6
第二節 醫療服務利用理論模式 13
第三節 自付醫療費用之相關研究 17
第四節 自付醫療費用負擔之相關研究 40
第三章 研究方法 42
第一節 研究設計 42
第二節 研究架構 43
第三節 研究假說 44
第四節 研究對象 45
第五節 資料來源 46
第六節 研究變項測量 49
第七節 資料篩選與處理 54
第八節 統計分析 57
第四章 研究結果 58
第一節 描述性統計 58
第二節 雙變項分析 64
第三節 多變項分析…………………………………………………67
第五章 討論……………………………………………………………90
第一節 研究方法討論 90
第二節 結果討論 92
第三節 研究限制 113
第六章 結論與建議 114
第一節 結論 114
第二節 建議 116
參考文獻 117
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