臺灣博碩士論文加值系統

骨質疏鬆症在已開發國家不只盛行率漸增，首發率也有攀升的趨勢，且皆與人口高齡化密切相關。骨鬆性骨折不只有著高死亡率，亦對患者帶來龐大的醫療費用，更對社會造成鉅額的醫療成本，應是政府更加正視的問題。雖然臺灣的全民健康保險有補助骨質疏鬆症之藥物費用，但有研究指出其門檻過高，有些病患因無法承擔自費的金額，而被迫選擇其他治療方式。
本研究目的為設計骨質疏鬆症之商業保險，輔助全民健康保險的醫藥費用，達到提升藥物使用率並有效降低骨質疏鬆症與骨鬆性骨折的傷害，最終降低整體社會醫療的成本。研究的過程採用2004年至2011年全民健康保險研究資料庫的骨質疏鬆症患者就醫資料，並配合FRAX的臺灣人骨鬆性骨折首發率，設計保險商品、計算保費、試算準備金並對利率做敏感度分析。
根據衛生福利部國民健康署，大部分的骨質疏鬆症藥品限於停經婦女或性腺功能低下男性使用，故保險商品之設計為針對50歲以上的人口。被保險人罹患骨質疏鬆症後給付方式為終身型新臺幣12,000元，然而若不幸再發生骨鬆性骨折，則有一次性新臺幣324,000元的給付。經計算所得的保費為男性新臺幣42,178元，女性新臺幣194,079元。骨質疏鬆症的盛行率在世界各地皆有上升的趨勢，不只人口老化，現代人的飲食與作息也有極大的關係。希望本研究可以提供相關單位，作為商品開發之參考。

Owing to the aging of population, the prevalence rate and incidence rate of osteoporosis in developed country have been increasing. Osteoporotic fractures not only have a high mortality rate, but also cause great medical expenses to the patients. Despite the fact that the National Health Insurance of Taiwan has subsidies, some studies have pointed out that its threshold is too high, forcing some of the patients to choose less effective treatments.
The purpose of this study is to design an insurance for osteoporosis, therefore improve the use rate of drugs, and reduce the damage of osteoporosis and osteoporotic fractures. Ultimately, the study aims to reduce the overall medical cost of the society. The study reviewed the data of osteoporosis patients from the National Health Insurance Research Database in 2004 to 2011, along with the osteoporotic fracture incidence rate of Taiwanese from FRAX. As a result, the study designed an osteoporosis commercial insurance with calculated premiums, reserves and has conducted sensitivity test for interest rates.
According to the Health Promotion Administration, Ministry of Health and Welfare, most osteoporosis drugs are limited to menopausal women or men with hypogonadism. Therefore, the insurance was designed for the elderly over 50 years old. Once the insured suffers from osteoporosis, the insured receives payment of a life-long NT$12,000. However, if a bone fracture occurs unfortunately, there will be a one-time NT$324,000 payment instead. The calculated premium is NT$42,178 for men and NT$194,079 for women. The prevalence rate of osteoporosis is increasing worldly, and it is not only the result of population aging, but also the lifestyle of modern people. Hope this study can provide as a reference for osteoporosis insurance.

誌謝 i
摘要 ii
Abstract iii
目錄 iv
圖目錄 v
表目錄 vi
第一章、緒論 1
第一節、研究背景 1
第二節、研究動機 4
第三節、研究目的 6
第四節、研究流程 8
第二章、文獻回顧 9
第一節、骨質疏鬆症的影響 9
第二節、臺灣骨質疏鬆症的狀況 10
第三節、骨質疏鬆症的經濟負擔 11
第三章、研究設計與方法 13
第一節、資料來源 13
第二節、資料處理 14
第三節、名詞解釋 18
第四節、研究方法 19
第五節、研究架構 20
第四章、研究結果 21
第一節、實證分析 21
第二節、商品設計 32
第三節、純保費計算 34
第四節、準備金計算與敏感度分析 38
第五章、結論與建議 41
第一節、結論 41
第二節、建議 42
參考文獻 43
附錄 48

Bliuc, D., Nguyen, N., Alarkawi, D., Nguyen, T., Eisman, J., & Center, J. (2015). Accelerated bone loss and increased post-fracture mortality in elderly women and men. Osteoporosis international, 26(4), 1331-1339.
Bliuc, D., Nguyen, T. V., & Eisman, J. A. (2007). Risk of subsequent fracture after low-trauma fracture in men and women. Jama, 297(4), 387-394.
Center, J. R., Nguyen, T. V., Schneider, D., Sambrook, P. N., & Eisman, J. A. (1999). Mortality after all major types of osteoporotic fracture in men and women: an observational study. The Lancet, 353(9156), 878-882.
Chan, D.-C., Tu, S.-T., Hwang, J.-S., Wu, C.-H., Lim, L., Huang, K.-E., . . . Yang, R.-S. (2013). Effectiveness of Nationwide Osteoporosis Nursing Specialist Training Courses in Taiwan. Osteoporosis Int.(24).
Chen, F.-P., Huang, T.-S., Fu, T.-S., Sun, C.-C., Chao, A.-S., & Tsai, T.-L. (2018). Secular trends in incidence of osteoporosis in Taiwan: A nationwide population-based study. biomedical journal, 41(5), 314-320.
Chie, W., Yang, R., Liu, J., & Tsai, K. (2004). High incidence rate of hip fracture in Taiwan: estimated from a nationwide health insurance database. Osteoporosis international, 15(12), 998-1002.
Cooley, H., & Jones, G. (2001). A population-based study of fracture incidence in southern Tasmania: lifetime fracture risk and evidence for geographic variations within the same country. Osteoporosis international, 12(2), 124-130.
Cummings, S. R., Black, D. M., & Rubin, S. M. (1989). Lifetime risks of hip, Colles', or vertebral fracture and coronary heart disease among white postmenopausal women. Archives of Internal Medicine, 149(11), 2445-2448.
Dawson-Hughes, B., Looker, A., Tosteson, A. N., Johansson, H., Kanis, J. A., & Melton, L. (2012). The potential impact of the National Osteoporosis Foundation guidance on treatment eligibility in the USA: an update in NHANES 2005–2008. Osteoporosis international, 23(3), 811-820.
Group, W. S. (1994). Assessment of fracture risk and its application to screening for postmenopausal osteoporosis. Report of a WHO Study Group. World Health Organ. Tech. Rep. Ser., 843, 1-129.
Hasserius, R., Karlsson, M., Nilsson, B., & Johnell, O. (2003). Prevalent vertebral deformities predict increased mortality and increased fracture rate in both men and women: a 10-year population-based study of 598 individuals from the Swedish cohort in the European Vertebral Osteoporosis Study. Osteoporosis international, 14(1), 61-68.
Ho, C.-A., Li, C.-Y., Hsieh, K.-S., & Chen, H.-F. (2010). Factors determining the 1-year survival after operated hip fracture: a hospital-based analysis. Journal of Orthopaedic Science, 15(1), 30-37.
Hwang, J.-S., Chan, D.-C., Chen, J.-F., Cheng, T.-T., Wu, C.-H., Soong, Y.-K., . . . Yang, R.-S. (2014). Clinical practice guidelines for the prevention and treatment of osteoporosis in Taiwan: summary. Journal of bone and mineral metabolism, 32(1), 10-16.
International Osteoporosis Foundation. (2019). Osteoporosis. Retrieved from
http://www.iofbonehealth.org/osteoporosis
Johnell, O., & Kanis, J. (2005). Epidemiology of osteoporotic fractures. Osteoporosis international, 16(2), S3-S7.
Johnell, O., & Kanis, J. (2006). An estimate of the worldwide prevalence and disability associated with osteoporotic fractures. Osteoporosis international, 17(12), 1726-1733.
Kanis, J. A., Delmas, P., Burckhardt, P., Cooper, C., & Torgerson, D. o. (1997). Guidelines for diagnosis and management of osteoporosis. Osteoporosis international, 7(4), 390-406.
Kanis, J., McCloskey, E., Johansson, H., Strom, O., Borgstrom, F., & Odén, A. (2008). Case finding for the management of osteoporosis with FRAX®—assessment and intervention thresholds for the UK. Osteoporosis international, 19(10), 1395-1408.
Kanis, J., Oden, A., Johnell, O., De Laet, C., Jonsson, B., & Oglesby, A. (2003). The components of excess mortality after hip fracture. Bone, 32(5), 468-473.
Kanis, J. A., Oden, A., McCloskey, E. V., Johansson, H., Wahl, D. A., & Cooper, C. (2012). A systematic review of hip fracture incidence and probability of fracture worldwide. Osteoporosis international, 23(9), 2239-2256.
Keene, G. S., Parker, M. J., & Pryor, G. A. (1993). Mortality and morbidity after hip fractures. Bmj, 307(6914), 1248-1250.
Leibson, C. L., Tosteson, A. N., Gabriel, S. E., Ransom, J. E., & Melton III, L. J. (2002). Mortality, disability, and nursing home use for persons with and without hip fracture: a population‐based study. Journal of the American Geriatrics Society, 50(10), 1644-1650.
Levy, P., Levy, E., Audran, M., Cohen-Solal, M., Ardellone, P., & Le Parc, J. (2002). The cost of osteoporosis in men: the French situation. Bone, 30(4), 631-636.
Lin, Y. C. & Pan, W. H. (2011). Preliminary analysis of bone mineral density among Taiwanese adults from 2007-2008. Retrieved from
https://www.iofbonehealth.org/sites/default/files/media/PDFs/Regional%20Audits/2013-Asia_Pacific_Audit-Chinese_Taipei_0_0.pdf
Lippuner, K., Golder, M., & Greiner, R. (2005). Epidemiology and direct medical costs of osteoporotic fractures in men and women in Switzerland. Osteoporosis international, 16(2), S8-S17.
Lorrain, J., Paiement, G., Chevrier, N., Lalumière, G., Laflamme, G.-H., Caron, P., & Fillion, A. (2003). Population demographics and socioeconomic impact of osteoporotic fractures in Canada. Menopause, 10(3), 228-234.
Magaziner, J., Simonsick, E. M., Kashner, T. M., Hebel, J. R., & Kenzora, J. E. (1990). Predictors of functional recovery one year following hospital discharge for hip fracture: a prospective study. Journal of gerontology, 45(3), M101-M107.
Marks, R., Allegrante, J. P., MacKenzie, C. R., & Lane, J. M. (2003). Hip fractures among the elderly: causes, consequences and control. Ageing research reviews, 2(1), 57-93.
McKinley, S., & Levine, M. (1998). Cubic spline interpolation. College of the Redwoods, 45(1), 1049-1060.
Merrill, R. M., Weed, D. L., & Feuer, E. J. (1997). The lifetime risk of developing prostate cancer in white and black men. Cancer Epidemiology and Prevention Biomarkers, 6(10), 763-768.
Michael, G. (Ed.). (2017). Demystifying ageing: Lifting the burden of fragility fractures and osteoporosis in Asia-Pacific (no report number). Hong Kong: The Economist Intelligence Unit.
National Institute of Health. (2019). Osteoporosis and fracture. Retrieved from https://www.bones.nih.gov/　
Orsini, L. S., Rousculp, M. D., Long, S. R., & Wang, S. (2005). Health care utilization and expenditures in the United States: a study of osteoporosis-related fractures. Osteoporosis international, 16(4), 359-371.
OrthoInfo. (2019). Osteoporosis and Spinal Fractures. Retrieved from https://orthoinfo.aaos.org/en/diseases--conditions/osteoporosis-and-spinal-fractures/
Parker, M., & Johansen, A. (2006). Hip fracture. Bmj, 333(7557), 27-30.
Riggs, B. L., & Melton Iii, L. (1995). The worldwide problem of osteoporosis: insights afforded by epidemiology. Bone, 17(5), S505-S511.
Roche, J., Wenn, R. T., Sahota, O., & Moran, C. G. (2005). Effect of comorbidities and postoperative complications on mortality after hip fracture in elderly people: prospective observational cohort study. Bmj, 331(7529), 1374.
Siris, E. S., Miller, P. D., Barrett-Connor, E., Faulkner, K. G., Wehren, L. E., Abbott, T. A., . . . Sherwood, L. M. (2001). Identification and fracture outcomes of undiagnosed low bone mineral density in postmenopausal women: results from the National Osteoporosis Risk Assessment. Jama, 286(22), 2815-2822.
Tinetti, M. E. (2003). Preventing falls in elderly persons. New England journal of medicine, 348(1), 42-49.
Trombetti, A., Herrmann, F., Hoffmeyer, P., Schurch, M., Bonjour, J.-P., & Rizzoli, R. (2002). Survival and potential years of life lost after hip fracture in men and age-matched women. Osteoporosis international, 13(9), 731-737.
Woolf, A. D., Dixon, A. S. J., & Eastell, R. (1988). Osteoporosis: a clinical guide: M. Dunitz London.
World Health Organization. (2019). Ageing and Life Course. Retrieved from
https://www.who.int/ageing/en/
Kruger, M., & Wolber, F. (2016). Osteoporosis: modern paradigms for last century’s bones. Nutrients, 8(6), 376.
Yang, N.-P., Deng, C.-Y., Chou, Y.-J., Chen, P.-Q., Lin, C.-H., Chou, P., & Chang, H.-J. (2006). Estimated prevalence of osteoporosis from a Nationwide Health Insurance database in Taiwan. Health Policy, 75(3), 329-337.
中華民國內政部戶政司（2019）。人口年齡分配。檢自：
https://www.moi.gov.tw/files/site_stuff/321/2/year/year.html
王寶璽（2002）。環境科學大辭典。檢自：http://terms.naer.edu.tw/
全民健康保險藥品給付規定（2013）
行政院衛生署國民健康局（2011）。骨質疏鬆症臨床治療指引。臺北縣：行政院衛生署國民健康局。
李瑋君, 韓岳津, 吳英黛, & 曹昭懿. (2007). 骨質疏鬆相關骨折住院病患之健保申報分析. 臺灣醫學, 11(1), 22-28.
陳立材, 施嘉慶, & 魏春生. (2015). 骨質疏鬆症之藥物治療簡介. 藥學雜誌, 31(2), 88-92.
陳美森, 陳綺華, & 陳學源. (2008). 骨質疏鬆症治療藥物-Teriparatide. 藥學雜誌, 24(4), 102-107.
郭耿南編著（2009）。2020健康國民白皮書。臺北市：行政院衛生署。
黃兆山編著（2017）。2017臺灣成人骨質疏鬆症防治之共識及指引。臺北市：中華民國骨質疏鬆症學會。
楊南屏, 楊榮森, & 周碧瑟. (2008). 提早因應高齡化社會的特殊醫療保健需求: 以骨質疏鬆症為例. 臺灣公共衛生雜誌, 27(3), 181-197.
葉慶輝, & 葉淑娟. (2007). 臺灣南部健檢成人骨質疏鬆症之盛行率與危險因子探討. 臺灣公共衛生雜誌, 26(6), 462-471.
熊昭、王英偉（2016）。2013年「國民健康訪問調查」結果報告（衛生福利部國民健康署委託之研究結果報告，編號：無）。苗栗縣：財團法人國家衛生研究院。
衛生福利部中央健康保險署（2010）。2001年ICD-9-CM疾病碼一覽表。檢自：　　　　　　
https://www.nhi.gov.tw/Content_List.aspx?n=B2F4F9610CEB71C0&topn=D39E2B72B0BDFA15。
澄清醫院中港分院（2018）。醫病共享決策輔助評估表。檢自：　　　　　　
http://www.ccgh.com.tw/QAdocument/CLINIC/201802200016骨質疏鬆的藥物治療有哪些選擇.pdf。