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研究生:顧于君
研究生(外文):Yu-Chun Ku
論文名稱:實施全民健保對家戶自付醫療費用結構的影響
論文名稱(外文):The effect of National Health Insurance on household out-of-pocket expenditure structure
指導教授:蒲正筠蒲正筠引用關係周穎政周穎政引用關係
指導教授(外文):Christy PuYiing-Jenq Chou
學位類別:碩士
校院名稱:國立陽明大學
系所名稱:公共衛生研究所
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:2016
畢業學年度:104
語文別:英文
論文頁數:42
中文關鍵詞:自付醫療費用全民健康保險差異中之差異法醫療支出
外文關鍵詞:Out-of-pocketNational Health InsuranceDifference-in-differenceMedical spending
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研究背景與動機
台灣從1995年3月1日起實施全民健康保險,開辦全民健保的主要目標之一就是希望提供民眾財務風險的保障,因此,我們有必要透過研究確認我們的全民健保成功減少哪部份的自付醫療費用。雖然台灣目前已經有許多文獻探討健保介入後的自付醫療費用,但多數研究都是在計算健保介入前後自付醫療費用的實際數字,對於全民健保險這個政策對自付醫療費用結構的影響是什麼反而所知甚少。但自付醫療費用的結構在全民健保實施後如何改變其實是一個非常重要的議題,因為過去的研究曾指出,特定種類的自付醫療費用是提升生命品質的關鍵,而其他的自付醫療費用則可能與必要的醫療較不相關。因此,為了瞭解實施全民健保的實際效益是什麼,探討全民健保對自付醫療費用的結構的影響有其必要與迫切性。

研究目的
透過次級資料分析,研究台灣實施全民健康保險對原本有醫療保險和沒有醫療保險的病患對自付醫療費用的影響是什麼,以及自付醫療費用的結構有什麼變化。另外,我們也評估開辦全民健保對商業醫療保險的影響。

研究方法
本研究使用1993-2000年的家庭收支調查進行研究,分析台灣實施全民健康保險的實質效益。家庭收支調查是以家戶為單位,每年由行政院主計處辦理的全國代表性調查。我們選出有公務員保險的家戶當成是我們的控制組,因為公務員保險所提供的醫療風險保障不只保障公務員本身還同時涵蓋他們的直系血親,相較於其他家戶,全民健保的實施對他們的影響相對最小,完全沒有社會保險的家戶則設為實驗組,比較兩組間自付醫療費用結構的差異。為了降低實驗組和控制組之間的選樣偏差,我們使用擴大實際配對 (Coarsened exact matching, CEM) 降低兩組之間的差異,最後的研究樣本中控制組有10,078戶,實驗組5,893戶。我們接著採用差異中之差異法 (Difference-in-difference,DID),計算沒有任何社會保險的實驗組和有公保的控制組健保實施前後的自付醫療費用的變化,並使用比率回應變項回歸 (Fractional response regressions) 進行分析,探討台灣在實施全民健保後,對自付醫療費用的影響,以及自付醫療費用結構的變化。

主要結果
本研究發現全民健保的實施對於家戶自付醫療費用有顯著的負面影響,自付醫療費用佔家戶消費支出的比重減少了1.24%,我們接著將自付醫療費用拆成三種不同的細項,分別是醫療照護自付費用、藥品支出和醫療器材,並發現健保實施分別對醫療照護自付費用和藥品支出都有顯著的負面影響,醫療照護自付費用佔家戶消費支出的比重減少了0.69%,藥品支出佔家戶消費支出的比重則減少了0.43%。然而,雖然健保實施對自付醫療費用及細項都有負面影響,但在結構上並未發現顯著變化。另外,根據國際公用的醫療費用測量標準 (A System of Health Accounts, SHA) 的規定,醫療保險的保費不屬於自付醫療費用的一部份,因此本研究將商業醫療保險的保費和自付醫療費用分別分析,我們發現健保實施對商業醫療保險有正向的外溢效果 (Spillover effect) ,商業醫療保險的保費佔家戶消費支出的比重增加了2.83%。除此之外,我們發現健保實施的政策效果對社經地位較低的家戶影響較大,社經地位越低的家戶,自付醫療費用的下降幅度和商業醫療保險保費的上升幅度皆越大。

結論與政策應用
台灣實施全民健康保險成功降低自付醫療費用佔家戶消費支出的比例,其中醫療照護自付費用和藥品支出都有顯著的減少,而且社經地位越低的家戶自付醫療費用下降的幅度越大,說明這個政策有達成他的初始目標,實質補助人民的醫療支出。此外,自付醫療費用的結構在健保實施後沒有顯著的變化,顯示我國的健保給付結構跟民眾所需相似。最後,全民健保的實施為商業醫療保險帶來正向的外溢效果,可能的解釋為,民眾因為政府推動全民健保對醫療保險的重要性有更多的了解和認識,進而增加了民眾購買商業醫療保險的意願。實施全民健康保險是許多國家衛生部門改革的主要目標,此研究發現台灣的全民健保透降低家戶自付醫療費用但不改變其結構的方式來降低民眾醫療方面的經濟負擔,促使國民得到更完整的醫療照護,這樣的結果或許可以提供相關政策制定和改革者作為參考。

主關鍵字
自付醫療費用、全民健康保險、差異中之差異法、醫療支出

Research objective
Taiwan implemented the National Health Insurance (NHI) program in 1995. The main objective of the NHI is to provide financial risk protection for the public. It is thus necessary to determine whether the NHI program has successfully reduced out-of-pocket (OOP) expenditure. Despite some studies on OOP are available, most of these studies only focused on how NHI affect the level of OOP expenditure, and very limited studies can be found on how OOP structure changes after the implementation of NHI. The structure of OOP is important because studies have shown that certain OOPs may be more related to essential treatments while others may not be as critical for improving quality of life. In order to estimate the actual benefits of implementing NHI, this study aims to investigate whether the implementation of NHI program affects the level and structures of OOP in Taiwan. Apart from OOP expenditure structure, we also evaluated the impact of NHI program on private health insurance spending.

Study design
We used the data of Taiwan Survey of Family Income and Expenditure (SFIE) released by the Directorate-General of Budget, Accounting and Statistics (DGBAS). The SFIE is conducted annually and consists of a national representative sample. Household is the unit of the analysis. We first identified people who were insured under the Government Employee Insurance (GEI) prior to 1995 (the year of NHI implementation). This group of people should be least affected by the implementation of NHI. Their household OOP structure was then compared to that of households without any form of social insurance prior to 1995 (the control group). To reduce selection bias, we used coarsened exact matching (CEM) to match the two groups using a number of available variables, including basic demographic variables, household income, occupation of the household head, family structure and residential location. The final study sample consists of 10,078 households in the control group and 5,893 households in the case group. We then conducted a differences-in-differences (DID) analysis with fractional response regressions to determine the effect of NHI on OOP structure.

Principal findings
The DID analysis showed that there was a statistically significant negative effect of NHI on OOP (a reduction of 1.24 percentage points in total household expenditure). The largest reduction was found in health care services (-0.69%), and pharmatheuticals (-0.43%). However, the structure of OOP expenditure has not reached a statistical significant change. Although private health insurance is not considered OOP under the international health accounting standard OOP, we still tested whether the implantation of NHI affected private health insurance purchases. We found a statistically significant positive effect of NHI on private health insurance purchases (an increase of 2.83 percentage points in the household budget share). In addition, we discovered that the NHI program had higher impact on households with lower socioeconomic status compared with higher socioeconomic status households.

Conclusions
The NHI program in Taiwan successfully reduced total OOP, and the breakdowns of household OOP has reduced for both health care services and pharmatheuticals. In addition, we found that the lower the socioeconomic status, the larger the decrease on OOP expenditure. This finding suggests that the NHI program has attained its preliminary goal for providing financial risk protection for the public. The structure of OOP expenditure has no significant change after the implementation of NHI. This indicates that the structures of NHI payment is similar to the original medical demand. Our results showed a significant positive spillover effect of NHI on private health insurance purchases, possible explanation may be that people gain more awareness on the importance of health insurance.

Implications for policy or practice
Implementing NHI is a major objective for many countries conducting health sector reform. Taiwan’s NHI reduced health financial burden by changing the level of OOP but leaving OOP structure unchanged, giving people a more complete health care systems.

Key words
Out-of-pocket, National Health Insurance, Difference-in-difference, Medical spending

Contents
致謝 i
中文摘要 ii
Abstract v
Contents viii
List of tables ix
List of figures x
Introduction 1
Methods 4
Results 14
Discussions 36
References 38

List of tables
Table 1. Distribution of medical consumption expenditure, 1994 and 1996 15
Table 2. Household characteristics of sample Population 17
Table 3. Comparison of distribution of medical consumption expenditure between case and control group in pre-NHI and post-NHI periods. 20
Table 4. Comparison of structure of out-of-pocket expenditure between case and control group in pre-NHI and post-NHI periods. 22
Table 5. Marginal effect of NHI on medical consumption expenditure 25
Table 6. Marginal effect of NHI on out-of-pocket structure 27
Table 7. Household characteristics of sample Population: quasi-case group 29
Table 8. Marginal effect of NHI on medical consumption expenditure: quasi-case group 33
Table 9. Marginal effect of NHI on out-of-pocket structure: quasi-case group 35

List of figures
Figure 1. Flow chart of thesis 9
Figure 2. Flow chart of sensitivity analyses 13


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