流行性感冒是一種容易快速傳染且造成地區性大流行的疾病，雖然政府宣導接種流感疫苗可以有效的防治流行性感冒的疫情，然而接種流感疫苗的人並不多，因此本研究將探討疫苗的有效性，以解決一般民眾對施打疫苗的疑慮。 我們以1998年至2012年的健保資料庫分析疫苗的有效性，分析方法以Python程式將資料分類並做運算，其中一方法以有打疫苗者和未打疫苗者的平均流感就醫次數作為判別疫苗的有效性，另一方法則是用bootstrapping來判別疫苗之有效性。 透過本研究的結果可以知道，6歲以下兒童和6歲以上65歲以下成人類別疫苗都是呈現有效的，但在65歲以上老人則是呈現疫苗無效，雖然如此，在死亡率的比較上，有打疫苗的老人死亡率則是低於沒打疫苗的老人，故仍建議民眾施打疫苗。

台灣地區由於社會經濟蓬勃發展，國民平均所得逐年增加，生活、飲食習慣有所改變，高熱量、高脂肪及低纖維食品成為國人食物主要來源之ㄧ，進而導致熱量和脂肪的過度攝取，及營養供給的不均衡。台灣1998年公告的第三次全國營養調查結果顯示，國人身體質量指數有上升趨勢。 身體質量指數偏低或過高都有較高的死亡率。很多的研究顯示，許多慢性疾病的罹患率和死亡率會隨者身體質量指數的上昇而增加，故肥胖本身是一個獨立的危險因素。根據衛生署最新的資料統計顯示，2005年台灣地區主要死亡原因腦血管疾病、心臟疾病、糖尿病、高血壓分別為十大死因的第二、三、四及十位。肥胖與醫療資源利用及醫療費用亦逐年上升。 本研究欲以身體質量指數為衡量指標，進行體重過重、肥胖者與台灣健保醫療資源利用是否相關性之實證研究探討，並了解其對健保財務負擔影響程度，是否值得重視。研究資料取自國民健康局於2001年執行之「國民健康訪問調查」抽樣樣本，連結健保利用資料，並採最小平方法（ordinary least squares，OLS）為實證分析之方法。本研究以全樣本及男性樣本之模型實證結果發現，身體質量指數過低或過高，都會增加健保門診費用效果；個人的身體質量指數對門診健保費用的影響，並非線性，而是呈現U型的曲線。值得注意的是，以女性樣本之模型，身體質量指數並未顯著地影響健保門診就醫情形，這可能是台灣女性平時較注重健康，會留意體重的變化，以防止體重體重過輕或過重而引起病痛。 關鍵詞：身體質量指數、健保支出、醫療資源利用 / The Body Mass Index (BMI) Impact to the Expenditure of National Health Insurance on Taiwan Abstract Due to economic grows vigorously on Taiwan, the average income per person increase extremely year by year. Consequently, the living style and eating habit have significantly changes in searching major foods always with high colorific, full fat and low fiber. Therefore, it causes the body absorbing excessively of the colorific and fat as well as in unbalance supply of nutrition. The result of the third Nutrition and Health Survey in Taiwan (NAHSIT) announced in Year 1998, the Taiwanese’ Body Mass Index was toward to rise. Either lower or higher of Body Mass Index is always subjected higher death rate. Many researches show, there are high correlation coefficient between high percentage of chronic morbidity and death and up trends of Body Mass Index. Therefore, the obesity itself will be an independent dangerous factor. According to newest statistics of National Health Administration, Year 2005 in Taiwan, the main death reason from brain blood vessel disease, heart disease, diabetes, high blood pressure are ranking at the second, third, fourth and tenth of top ten cause of death respectively. Also the obesity is significantly associated with excess medical care cost and resources of hospitalization rising up year by year. This Research tends to apply Body Mass Index to be an indication of health measuring. Study and discuss the high correlation coefficient between overweighed and obesity and consuming resources of hospitalization of Taiwan. Meanwhile, it deserves paying more attention for understanding the influence level of financial to health insurance. The present data were derived from Bureau of Health Promotion which committee was implemented the National Health Interview Survey at Year 2001 and directly link to expenditure of National Health Insurance. The study method is adopting ordinary least squares (OLS) for real case analysis. This research discovered with the result of study model using completed samples and male samples, either lower or higher of the Body Mass Index will increase outpatient medical care cost. And there was a U-shaped association between Body Mass Index and outpatient medical care cost but liner-shaped. It deserves paying attention to the model of the samples of female, the Body Mass Index do not obviously encouraging them to see a doctor. Because of Taiwanese women relatively focus on the health regular, will look out for the change of the weight, in order to prevent the weight from being underweight or overweight and causing the illness. Keyword: Body Mass Index, expenditure of health insurance, resources of hospitalization

台灣一家人壽保險公司曾推出一個健康險廣告，強調「全民健保不夠」，甚至在網路上請網友票選「健保哪裡最不夠」，引起健保局注視，行文要求業者修正資訊錯誤。此舉，是否代表台灣的保險業者很擔心全民健保對個人健康保險購買產生替代效果。也就是說，全民健保會降低個人健康保險購買的意願。因此，要用強調「全民健保不夠」這支廣告來降低這種不利的衝擊？ 全民健保是基礎型保險，每人都應參加；如果民眾覺得基礎的保險不足，當然有權選購其他商業保險，基於此因，於是商業化的個人健康保險應運而起。因此，本文的研究目的，將透過台灣壽險公司金融保險從業人員之家戶及個人已投保個人健康保險之橫縱面資料（cross-sectional data），及每年總繳交全民健保保費之數據，利用最小平方估計式，建立家戶及個人購買個人健康保險之迴歸模型，探究全民健保與個人健康保險兩者購買行為，所呈現關係為替代或互補，並進而了解個人變數、家戶變數對於個人健康保險購買行為之影響。 實證結果發現，全民健保實施12年餘，現今台灣全民健保與個人健康保險之間呈現正向顯著之互補關係。此外就家戶組研究分析顯示，家戶人數多、要保人年齡高、教育程度低、家戶所得高者，對於個人健康保險購買需求皆有顯著正向影響。且家戶組居住在金馬地區者相對於其他地區，對個人健康保險購買意願及需求顯著偏高。 就單身個人組研究結果分析發現，單身女性在年齡、教育程度以及年所得三項變數，與實際年負擔之個人健康保險費應變數之間均具有顯著影響；單身女性年齡及年所得二項變數，皆達1﹪的顯著水準，且其值皆為正，顯示女性年齡高、年所得高者，對於個人健康保險有較高購買需求；相對的，單身女性之教育程度變數，其結果亦達1﹪的顯著水準，但其值為負，顯示單身女性教育程度高者反而較無意願購買個人健康保險。單身男性，則在年齡、年所得及居住地區三項因素呈現顯著正向影響，其男性年所得居於101萬至200萬元者達5﹪顯著水準，其係數值為正，相較其他年所得者，對個人健康保險購買需求顯著偏高。 本研究亦發現，單身男性之居住地區變數估計結果發現，係數為顯著正值，其結果說明居住在北部、中部、南部、東部者其購買個人健康保險意願，相對高於金馬地區居住者。然而單身女性在居住地區變數之研究結果發現，係數均為不顯著的正值，代表單身女性無論居住地區為何，對其購買個人健康保險意願皆無明顯差別，此結果與單身男性具有差異性。

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從世界各國實施社會性健康保險的經驗來看，醫療費用上漲是共同面臨的難題。本論文從道德危險的角度探討醫療服務需求面及供給面的濫用與浪費，針對部分負擔與支付制度抑制道德危險的效果，分析世界主要國家制度改革的的成效，以供我國實施全民健保的參考。 從文獻探討中可以知道：消費者會因自付價格下降，引發需求面的道德危險；而基於消費者無知及資訊不對稱之特性，醫療服務供給者會誘發道德危險。面對道德危險，實施醫療費用部分負擔可抑制醫療利用，其中以定率負擔制最能發揮功能。而具有正面誘因的支付制度，能鼓勵醫院及醫師增進醫療提供之成本控制、效率及公平性，其中，以論病例計酬制最具這些功能。 由本文實證研究的結果可看出，要有效抑制道德危險，應該注意以下幾點： 1.高部分負擔不一定對抑制道德危險有效，在商業醫療保險普及下，反而會增加低收入者的負擔。 2.為避免改革只收到短期的效果，必須同時在支付制度及部分負擔上做持續性的改革。 3.健康照護制度中的成員，本身對政策之配合度也是影響制度改革能否收到成效的重要因素。 4.影響醫療利用的因素錯綜複雜，仍有許多部分負擔及支付制度以外的因素在影響醫療資源的使用，在實施制度改革時，應同時也把其他因素納入考慮中。

八零年代起，我國政府即對生技新藥產業寄予厚望，為促使生技醫藥產業成為明星產業，行政院也自1982年起，將生物技術列為國內八大重點科技產業之一，並投入相當大的金額補助產業之發展；至今已歷經35年，卻仍僅極少由台灣本土研發之新藥成功上市。 本研究主要採用文獻探討以及個案訪談作為主要的研究方法，先藉由文獻探討建立起論文整體之架構，之後再透過兩間國內本土新藥研發公司的訪談加以實證。本研究探討衛生福利部中央健康保險署現行之藥價政策對於國內本土研發新藥上市策略之影響，以及《全民健康保險藥物給付項目及支付標準》第17-1條實施後，是否有助於國內本土研發新藥上市的問題，進行深入分析與探討。而可得到以下初步之研究結論： 一、我國政府的鼓勵措施對於台灣的新藥發展之影響 我國政府多以科技專案補助臨床試驗的形式協助國產新藥公司研發新藥。 二、比較在台灣及其他國家研發新藥的鼓勵措施 我國與日本政府皆有提供新藥不同形式之新藥相關加成給付；本研究未發現韓國政府有針對新藥提供相關加成給付措施。 三、台灣健保藥價制度與台灣研發的新藥藥價 1.對新藥開發類型之國產新藥公司而言，期望政府在設定參考藥品之藥價時，可以選擇使用參考藥品之初始藥價作為reference price。 2.對新藥開發類型之國產新藥公司而言，期望在選擇參考藥品時，可以鼓勵創新藥理作用之新藥、跳脫侷限治療相同疾病用藥之思維。 3. 對新藥開發類型之國產新藥公司而言，全民健康保險藥物給付項目及支付標準第17-1條規範參考類似藥品之十國藥價不合理，因為若以台灣為第一上市國，則尚未在其他國家取得藥價，此法規自相矛盾。 四、我國藥品政策與台灣研發新藥上市策略 對新藥開發類型之國產新藥公司而言，健保給付國產新藥之藥價無法符合國產新藥公司期望之藥價，國產新藥公司改採取由病患自費購買藥品的方式銷售。 / Since the 1980s, our government has placed great hopes toward the industry of biotech and new drugs in order to take such industry to a booming stage. The Executive Yuan has also listed biotechnology as one of the eight key technological industries in the country since 1982. Furthermore, large amounts of subsidies have aided the development of this industry. This industry has been in development for 35 years, however, very few new drugs developed by domestic pharmaceutical companies have been launched successfully in Taiwan. This study mainly used literature review and case interview as the main research methods. Firstly, the structural development of the thesis was built on reviewing past literature. Then, the empirical study was conducted through interviews with two domestic new drug research and development pharmaceutical companies. This study examined the impact of the current drug pricing policy of the National Health Insurance Administration on the domestic market for research and development of new drugs. Moreover, the effectiveness of implementation of Article 17-1 of the "National Health Insurance Drug Payment Program and Payment Standards" was investigated in relations to the development of domestic new drugs in the country. In-depth analysis was employed to explore and discuss our research. The following preliminary conclusions were obtained: First, the influence of the government's encouragement measures on the development of Taiwan's new drugs was examined. Results revealed that the government have mainly been funding domestic new drug companies to research and develop new drugs through subsidized clinical trials of technological projects. Second, the encouragement measures for developing new drugs in Taiwan and other countries were compared. Results showed that both Taiwan and the Japanese government have been providing new forms of new-drug-related premiums for new drugs. However, in this study, we did not find the Korean government providing relevant premiums measures for new drugs. Third, we explored the drug price system of Taiwan's national health insurance and the prices of new drugs that were developed domestically. We found that 1) for domestic pharmaceutical companies that specializes in developing new drugs, they anticipate the government to use the initial drug prices of the reference drugs as reference prices when setting the prices of reference drugs; 2) for domestic pharmaceutical companies that specializes in developing new drugs, they anticipate the government to encourage innovations of new drugs leading to new pharmacological effects and overcoming the idea of limiting treatment to the same illness or conditions when they are selecting reference drugs; 3) for domestic pharmaceutical companies that specializes in developing new drugs, under Article 17-1 of the "National Health Insurance Drug Payment Program and Payment Standards", the statement that drug prices should be referenced from ten countries is unresonalbe because prices cannot be obtained from other countries if Taiwan is the first country to launch the new drug. Thus, the regulation is contradictory in itself. Fourth, we examined Taiwan’s pharmaceutical policy and the marketing strategy of new drugs developed domestically. Findings showed that for domestic drug companies that specializes in developing new drugs, when the drug payment provided by the national health insurance does not meet the drug prices set by the new drug companies, these companies employ a strategy that the patient pay for the drugs instead of the national insurance system.

台灣的全民健康保險於1994年開辦，至今已邁入第15年，在國際上屢獲好評，惟開辦以來面臨最大壓力即是維持保險財務收支平衡，受到國內人口老化、醫療科技進步，以及民眾就醫需求增加等因素之影響，全民健保所應支付之醫療費用逐年增加，同期間保險費收入，雖亦隨著被保險人薪資之上漲而有微幅增加，但其速度遠不及醫療費用來得快，平均醫療支出成長仍高於保險收入成長達二個百分點，使財務收支存在結構性不平衡問題。然在討論保費調漲時，各界即對健保醫療費用浪費、醫療弊端等問題提出質疑，使得醫療違規弊端成為反對調漲保費重要議題，也突顯醫療違規查處的重要。 本研究的目的係藉實證資料分析，驗證健保局行政作為的成效，以健保局於2006年8月16日至2006年10月15日間辦理之「費用申報異常稽核專案（牙醫第四次）」的訪查牙醫診所之訪查前後費用資料，對照未受訪查的牙醫診所前後費用資料比對分析，由資料的統計分析，檢視健保局在訪查、處分、移送法辦等不同作為後，醫療院所費用申報改變情形 由本研究實證數據顯示健保局的查處確有成效，且隨時間增長，效果更大。健保局訪查後牙醫診所申報之人次、點數均較訪查前明顯減少，行政處分及移送法辦之數據雖未顯著證明有申報費用減少，然健保局之訪查、行政處分及移送法辦等作為是環環相扣，均是違規院所查處的必要環節，看診人次及點數之減少即時反應於訪查後，應是經訪查的院所害怕被查到有違規事證會受健保局違規處分及違法移送法辦的行政作為而所作之改變，訪查、行政處分及移送法均有其效果。

根據世界上大多數實施全民健保國家的經驗，設計良好的支付制度是控制醫療費用不正常成長的重要方法之一。我國的全民健康保險亦有利用論病例計酬支付制度來控制醫療費用於合理的範圍內。唯因國內較缺乏有關於論病例計酬實施後財務績效之實證研究，因此本研究乃嘗試就個案醫院實施論病例計酬支付制度後，分析其財務績效與經營績效之關聯性。 本研究以某醫院三個院區，自民國83年1月到民國88年11月，共71個月的每月住院資料進行實證分析，獲致研究結果如下： 1.在不同階段（論病例計酬支付制實施前、論病例計酬支付制實施初期、論病例計酬支付制實施後期）的經營績效方面，在論病例計酬支付制實施後，佔床率及病床週轉率有顯著的上升，平均住院日顯著的下降。再從迴歸實證結果發現病床週轉率之增加及平均住院天數之減少與論病例計酬支付制度的實施有顯著之相關性，而佔床率的增加則無法推論是因論病例計酬支付制度的實施，故整體而言，論病例計酬支付制對大部分的經營績效仍是有顯著的改善。 在不同階段的財務績效方面，淨利率與資產報酬率在論病例計酬支付制實施前到實施初期是變差的，但到了實施後期有改善的情況。至於每日平均住院成本是顯著的上升。 2.在財務績效對經營績效關聯性之研究方面，本研究結果顯示，淨利率及資產報酬率與佔床率有顯著的正相關，但與平均住院日呈不顯著的正相關，但與平均住院日則無顯著的相關。論病例收入百分比對淨利率與資產報酬率亦無顯著的相關。

目前健保局所能查核到的違規案件來源有五項，即民眾檢舉、投保單位經辦人檢舉、審查費用時發現異常而移辦、專案稽查、繳回之健保卡發現異常。但只有審查費用流程應用電腦檔案分析可透過大量的資料分析方法篩選出異常院所。然而，電腦檔案分析只能偵測醫師的服務量是否「偏離常態分配」，亦即只能偵查出某些醫師或院所可能做了過多不必要的服務，而無法偵測出虛報或詐欺等行為。 因而，本研究透過大量詐欺文獻回顧，發現其中Bolton & Hand (2002)指出一個最佳的例子為應用Benford定律的數字分析。Benford定律即是凡符合此法則的資料中，其第一位數的值越小者則出現的頻率就越大，而數值越大者出現的機率就越小。近幾年，Benford定律被應用在不同領域的舞弊或詐欺的審查流程中。 由於目前尚未有專文探討運用Benford定律於臺灣健保醫療費用異常之相關研究。本研究以Benford定律為基礎，利用健保研究資料庫的1999至2003年住院全部及門診抽樣的申報資料進行實證，步驟上有三：一、進行全體住院及門診機構的整體實證，二、檢視單獨以數字分析法是否可以找出異常機構，三、提出一個智慧型費用異常偵測模型並實證其效果。 本研究結論有三： 一、健保特約機構中，住院機構的健保費申請數字符合第一位數的Benford定律，第二、第三及第四位位數不符合。而其中的一般費用部分符合第一、二、三、四位數的Benford定律，論病計酬案件則只有第一位數符合。至於健保費的申請數字之第二、第三及第四位數不符全之原因為論病計酬案件不符合Benford定律，此乃因為論病計酬案件之特殊計價方式所造成。 二、本研究指出單獨應用Benford定律的數字分析方法檢驗的確能找出異常院所，但同時也容易將正常院所誤判為異常，在利用卡方檢定、Cramer’s V統計值判斷法，無論是住院或門診機構，由於鑑別度不高造成整體正確率不佳，由此可推論單純利用數字分析法不足以檢驗出異常院所，因此需要再進一步結合其他工具。 三、本研究所建構的智慧型費用異常偵測模型，是以GHSOM類神經網路進行變數選取工作，找出數個變數群組後，分別利用RBFNN(徑向基類神經網路)、GRNN（通用迴歸類神經網路）及ERNN（Elman反饋式類神經網路）等進行異常院所預判，並以逐步邏輯斯迴歸模型作為Benchmark，結果是以逐步邏輯斯迴歸模型所構建的線性模型得到比較好的效果，本研究推論原因可能為應用Benford定律的衍生指標和異常/正常院所之間就存在線性關係，因此可以利用邏輯斯迴歸模型來預判，並利用類神經網路模型加以佐證之。 因此，本研究希望利用Benford定律的計算智慧技術能運用於健保資料庫，進行大規模電腦初步審查，找出更多不良醫療院所之異常申報之來源，以提供實地查核進而查到真正違規之醫療院所，如此可遏止醫療院所之犯意，進而節省健保支出，健全其財務收支平衡，為健保永續經營貢獻一份心力。 / There are five sources of illegal medical cases checked by BNHI (Bureau of National Health Insurance): reported by public, reported by the operator of insured unit, unusual findings while auditing expenses, special case audit, and unusual findings for returned health insurance cards. The abnormal medical institutions can only be found out by analyzing digital data in the source of auditing expenses. However, the digital data can only detect whether the physicians’ service deviates from the normal distribution (excessive unnecessary service offered by some physicians or hospitals), instead of the false claim of medical expenses and fraud behavior. Thus, by reviewing a lot of fraud literature, this study finds the best example in Bolton & Hand (2002) is digit analysis of Benford's Law. Benford's Law points that the smaller the first digit is, the more frequent the digit shows, vice versa. In recent years, Benford's law has been applied in fraud review process in different fields. So far no specific article has applied Benford's Law in the research related to the BNHI medical expenses, so we did a study using inpatient (total) and outpatient (sampling) data from 1999 to 2003. There are three steps in this study: 1. Overall empirical study of all inpatient and outpatient medical institutions. 2. Try to find out the unusual medical institutions only using digit analysis. 3. Find out a smart anomaly detection model and verify its effectiveness. There are three conclusions of the study: 1. For the health insurance expenses applied by the BNHI-contracted inpatient institutions, the frequency of the first digit accords with Benford's Law, while the second, third, and fourth digits does not accord with Benford's Law. For the general health insurance expense, the frequencies of the first, second, third, and fourth digit accord with Benford's Law. While only the first digit meets Benford's Law for cases paid by disease, as its special pricing method causes the different frequencies of the second, third, and fourth digits of health insurance expenses. 2. This study shows that the digit analysis of Benford's Law does contribute to find out the abnormal institutions, but also pay the price of misidentify the normal institutions. By using chi-square test and Cramer's V statistics method, the low discrimination rates of both inpatient and outpatient hospitals leads to poor overall accuracy. It suggests that the simple method of digit analysis is insufficient to test the abnormal institutes, and further investigation with other tools is requested. 3. This study establishes a smart anomaly detection model of health insurance expense, which is based on variable selection with GHSOM neural networks to identify the optimal model, and then uses RBFNN (radial basis function neural network), GRNN (general regression neural network), and ERNN (Elman recurrent neural network) to predict the abnormal institutions. Comparing RBFNN, GRNN and ERNN with the stepwise logistic regression model as the Benchmark, the study concludes that the linear relationship between derived indicator of Benford's Law and abnormal/normal institutions exits. Therefore, we can predict by logistic regression model and verify by neural network model. The study intends to apply the smart technology of Benford's Law to the large-scale preliminary review of the National Health Insurance database, which can help to identify the sources of the anomaly expenses of medical institutions and find out the fraud ones. Therefore, the decreasing fraud of medical institutions will cut down the health insurance expense for financial break-even. We hope we can contribute to the sustainable development of health insurance.。

摘要 本文以民國85年7月至民國89年6月國家衛生研究院全民健保資料庫中關於牙醫醫事服務之相關資料，探討我國牙醫總額支付制度之實施，是否達到醫療費用成長率抑減及提昇效率之預期目標。研究結果顯示，以總額支付制度前後二年牙醫價量變化觀之，平均申報件數下降4.05％，而其申報金額之成長率為3.9％，低於協商之醫療費用成長率8％。而資料包絡分析之研究結果發現，總額支付制度實施後，全體醫院之平均純產出距離函數與全體平均產出距離函數均有攀升之現象，表示總額支付制度之實施，對於牙醫醫療院所產出效率之提升有正面之助益。本研究欲分析牙醫醫療院所生產力之變動是否與總額支付制度之實施相關，故利用前述DEA模型求得之純產出距離函數平均值與整體產出距離函數平均值，進行Tobit迴歸模型分析。實證結果顯示，總額支付制度別之迴歸係數為正，表示該制度實施後，牙醫醫療院所之生產力優於實施前，故總額支付制度之實施，對於牙醫之生產力改善有正面助益。而實證結果亦顯示，醫事機構之權屬別、評鑑等級別及健保分局別的不同，亦會造成其生產力之差異。 / Abstract Using dental services data from July 1996 to June 2000 in NHI, this study examines the effects of Global Budget on the operating efficiency of dental care. The results of this study indicate that after the implementation of the Global Budget system, the claimed number of cases of dental services reduced by 4.05％, and the claimed charges of dental services increased by 3.9％, below the allowed expense increase ratio. And the results of Data Envelopment Analysis (DEA) show that both CRS and VRS increased after the implementation of the Global Budget system, indicating that implementation of the Global Budget system improves the efficiency of dental care. This study also uses Tobit regression model to examine whether the improvements in the efficiency of dental care are related to the implementation of the Global Budget system. The results indicate that after implementation of the Global Budget system, the efficiency of dental care became better. This study also found several hospital characteristics are associated with the efficiency of dental care.