摘要 平均壽命因死亡率下降而延長以及主要死因轉變為中老年疾病或慢性病，尤其中老年疾病與慢性病必須長期治療且不易根治的特性，使得高齡化社會對於醫療保健的需求將逐漸上升。基於上述背景本文以全民健保資料庫重大傷病資料研究台灣地區在壽命延長以及死因轉變之下醫療需求以及疾病負荷，其中醫療需求研究是以保險精算的方式推估未來台灣地區醫療需求金額以及每人平均門診醫療費用成本；疾病負荷研究是以生命表的方式計算因疾病損失年數與健康餘命分別以死因除外的方式以及健康餘命佔平均餘命的比例分析死因轉變對於國民壽命與健康存活時間的影響。研究中發現醫療需求有以近似線性方式上升的可能，醫療費用成本也隨之逐漸上升，醫療費用的上升趨勢將形成商業醫療健康保險的挑戰；在壽命延長以及死因轉變之下因疾病損失年數有上升的趨勢，並且若中老年與慢性疾病發生率持續不變健康存活時間佔平均壽命的比例將逐漸下降。 / Abstract The health care demand becomes larger and larger in the aging society result from the improvement of mortality and the geriatric and chronic diseases become major dead causes now. Under this circumstance, we aim to evaluate the future health care demand and the burden of disease in Taiwan by using critical illness and injury data among National Health Insurance database. In this research, we evaluate the future health care demand amount and outpatient expenditure per capita in Taiwan in actuarial way and evaluate the burden of disease by calculating the year lost due to disease and health life expectancy. According to research result, we argue that the demand of health care is increasing in almost linear way and the increase of health care cost becomes the important challenge to commercial health insurance. In additional, the year lost due to disease is increasing and the proportion of health life expectancy to life expectancy is decreasing result from life becomes longer and longer and the change of major dead causes.

在全民健保實施後，龐大的醫療器材商機，大部分由國外大廠分食，落實醫療器材產製能力本土化來爭取商機，已是刻不容緩。台灣醫療器材小廠在面對規模100倍以上之歐美大廠之強勢競爭下，適者生存之外，要如何脫穎而出。 本研究主要以台灣醫療器材小廠，聯合骨科器材公司為例，分析影響經營決策因素，進而探討聯合骨科之經營決策方向；以及分析影響融資決策因素，進而探討聯合骨科之融資規劃方向。 經本研究分析，該公司競爭策略，在產品及市場擴張策略方面，應採提高公司OEM外銷比重；在差異化及品牌策略，應採彈性配合客戶需求，提供差異化之產品服務以及採高品質中低價位策略外銷。 該公司融資規劃，在萌芽草創階段，公司仍未獲利，融資策略應以長期負債及自有權益資本為主。當公司進入成長階段時，則應發揮財務槓桿，在資產報酬率足以支付舉債的資金成本條件下，舉債程度愈高，股東權益報酬率則愈大。

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

本研究循著社會脈絡的發展，選擇醫學為最主要的反思對象，企圖探討醫學如何扭轉我們對死亡的認識，以及改變我們對於死亡的觀感。論文所探討的課題主要環繞兩個主軸來加以分析 ： 1.醫學介入 分析醫學專業具有那些特質，其特質是如何影響人類生活的諸多面向，特別是介入臨終與死亡的過程、主導死亡發生的時間、空間是怎樣的面貌，此外，臨終者在醫療系統的隔離以及限制之下，會產生什麼樣的後果。 2.臨終關懷 當臨終期不可避免地延長，反省一般醫療種種的作為，一方面針對醫療行為提出可能的改進措施，以扭轉現代死亡與臨終所面臨的境況，男方面協助患者與周遭的親友面對日益延長的臨終期，使死亡回復過往平和親近與自然的原貌。此外，除了醫療之外，患者在臨終時期，該如何透過心境的轉換以正面地看待死亡？而對於一般人而言，透過對臨終者的關懷，又能得到什麼樣的啟示？種種現代性社會所面對之臨終課題，即是本篇論文擬深究探索的主要論題。 關鍵字：醫療化、臨終、平和死亡、安寧療護

關鍵字：醫療器材公司、經營策略、關鍵成功因素 論文摘要 在台灣實施全民健康保險制度以及加入WTO後，各種內外在環境的改變，促使公司的經營型態也隨之改變，在醫療器材產業競爭日趨激烈的環境下，醫療器材公司應該採取何種經營策略，才能使其在競爭激烈的環境中保有競爭優勢，是本研究主要的研究目的。 本研究的架構係採用Aaker的理論架構來進行內外在分析與策略規劃。整個研究架構分為四個階段：一、首先進行內外在分析，以界定外在環境中的機會與威脅，以及該產業的關鍵成功因素，並了解個案公司所擁有的優劣勢。二、根據以上分析，歸納出該公司所面臨的問題。三、提出可行的策略，在該策略下擬定競爭策略與營運策略。 經過本研究分析後發現國內醫療器材業的關鍵成功因素為：先進醫療器材的引入、良好的產品品質水準、行銷服務系的建立、充裕的資金、銷售人良的專業能力以及配合政府的政策。 從內外在環境分析及條件前提來看，本研究建議個案公司最適合採取成長策略，才能發揮個案公司的核心能力，尤其是應該在短期對國內市場採行產品擴張策略，在長期對國外市場採取地理擴張策略，以及適度地從事向前整合的多角化。產品擴張策略包括引進先進的醫療器材產品，以及服務的差異化；地理擴張策略主要為努力爭取國際大廠在中國大陸的產品獨家代理權；向前整合的多角化則是配合政府生物科技產業計晝，與原廠合作生產具有潛力的醫療器材產品。

醫療糾紛中涉及醫師說明義務違反之相關案例逐漸增加，然而何謂醫師說明義務？醫學院課程安排上隻字未提，而我國法律對其之規定為何，其規定是否能讓醫師有標準可以遵循，常常造成臨床醫師的困擾。從整理我國之相關法律規定出發，來尋找醫師說明義務的法律依據。就我國法而言，以契約法來思考，通說歸類為委任契約，或亦有認為無法以典型契約類型來歸類醫療契約，在適用上可以適用或類推適用委任契約之相關規定，在某些適用上會與醫療倫理相牴觸之下，仍然可以依民法第一條之規定，以習慣或法理從誠信原則出發，找到醫師說明義務之依據。以侵權行為法的思考，醫師說明義務的理論基礎有二，且其並不互相衝突。其一，以阻卻違法事由出發，且經由透過對病患同意其真摯性之要求，來架構醫師的說明義務。其二，醫師的說明義務納入醫師對病患的注意義務中，即是以過失的概念來架構醫師的告知說明義務。不論從契約法或侵權行為法之角度，均應肯定醫師在從事醫療行為時負有說明義務。此外比較美國及德國對醫師說明義務之相關理論發展與法律規定，從比較法之角度，來思考在我國相關法律規定中，醫師說明義務規定不足之處如何能有所補充。在醫師說明義務的履行方面，在現行法律規定之下，從說明義務實踐時所可能面對的個個面向，包括說明的主體、說明的時間點、說明的對象、說明的方式、說明的項目、說明的標準等，嘗試在理想與現實之間找到一個平衡點，希冀醫師在履行說明義務時能有所遵循。

本文將負面醫療結果(醫療傷害)統稱為醫療事故(medical incident)，而醫療事故中又分為醫療過失(medical negligence)、醫療不幸（medical mishap，又名醫療災禍）及醫療意外(medical accident)三種情況。造成醫療傷害可能是因為醫療的過失責任，也可能是無醫療過失責任，本文特意將無醫療過失責任再細分為無過失責任、非過失責任與無法律責任（自然死亡或自然病程）三種，並將「無過失責任」no fault liability一詞泛以「無關過失責任」稱之；醫療行為中可預知的合併症與副作用的「醫療不幸」及不可預知、不可抗力的「醫療意外」屬非過失責任範疇，而不可避免性的自然死亡及自然病程，則屬無法律責任的範疇。 責任負擔可分為賠償、補償、救濟三種。賠償者，以不法之侵權行為，致使他人受損害時，因而填補其所受之損害，謂之賠償，英文為indemnity。補償者，指根據該法所指定的人員敲定的額度提供的金錢補助，而不是指針對不法行為或違反契約依法起訴所獲得的補償性賠償金，英文為compensation。救濟者，特別指由國家向貧困者提供的財政幫助，英文為relief。 過失責任的歸責原因是醫療疏失，所以是以損害填補原則及不當得利禁止原則，以填補受害者所受損害及所失利益；因此，過失責任要負的是損害「賠償責任」。非過失責任的歸責原因包括醫療不幸（即副作用、合併症）與醫療意外兩種，因為醫師客觀上已盡注意義務，不論有無結果預知義務或結果迴避義務，醫師已盡力防阻，仍不免發生醫療傷害，故並無醫療疏失可言，應由國家社會對受害者予以救濟；因此，非過失責任理應由福利國家的救濟制度來負責。無關過失責任no fault liability的歸責原因是危險責任，針對所有醫療事故，不論對錯無關過失下，只要有了醫療傷害，加害人就予以被害人限額補償的基本保障。因為醫師身為危險責任主體，依報償責任理論（利之所存，險之所擔）、危險控制理論及危險分擔理論下必須承擔危險責任，因以，無關過失責任應負醫療事故補償責任。 賠償、補償、救濟三種責任負擔都可以分別採用基金模式或保險模式來解決；本文則認為，醫療過失責任宜採取醫師專業責任保險，予受害人損害賠償。醫療無關過失責任宜採取醫事人員強制責任保險，輔以醫療事故特別補償基金，予受害人基本保障補償。醫療非過失責任宜採取醫療風險救濟基金，予受害人風險救濟，急難救助。 故本文結論提出事故補償、風險救濟、損害賠償三階層的保險與基金制度架構，以解決醫療糾紛民事責任問題即；第一層事故補償—針對醫療事故，以醫事人員強制責任保險無關過失，限額補償；第二層風險救濟—針對醫療意外，整合醫療風險救濟基金定額救濟；第三層損害賠償—針對過失責任，以醫師責任保險損害填補。 / In this paper, we study negative outcomes associated with the delivery health care, which are collectively referred to as “medical incident”. This is further divided into “medical negligence”, “medical mishap” (also known as “medical disaster”), and “medical accidents”. Medical injuries may be in consequence of medical negligence or otherwise, that is they may be with fault or without fault. In this paper we further medical injuries without fault into three categories: (1) liability regardless of fault, (2) liability without fault, and (3) no legal liability. Notably, we refer to “no-fault liability” as “liability regardless of fault” to better distinguish its legal implications with respect to other kinds of medical injuries without fault. Predictable complications and side effects of medical treatments are considered “medical mishap”; unavoidable natural death or nature course of disease have “no legal liability”. The burden of duty can be divided into three categories: indemnity, compensation, and relief. Indemnity is secondary to the violation of rights leading to injury and damages. Compensation is set by appointed experts and given in direct consequence of the occurrence of the injury, and is independently of the determination of legality and contract fulfillment. Relief specifically refers to financial assistance given by government entities to those in need. At-fault liability follows medical negligence, and as such indemnity is given for reparation of damages and the prohibition of gains from the provision of negligent medical care. Causes of liability with no fault include medical mishaps and medical accidents. In these cases, the physician has fulfilled duties as medical professionals and in so doing have done their best to prevent medical incidents. Nevertheless due to circumstances beyond control, medical injuries occur. Because there is no negligence on the part of the physician, these losses are ideally dealt with by the governmental agencies. Liability regardless of fault attributes liability based on risk alone. Under this system, for all medical incidents, whether or not they are the consequence of negligence, the victim receives relief at a pre-determined amount. This relief serves as the basic protection of patients. Since the physician as the chief medical care provider is also at the center of medical risk, by principles of risk management, liability regardless of fault should in addition be organized as medical incidents compensation. The three forms of duty burden–indemnity, compensation, and relief–can be organized either as foundations or as insurances. We argue that duty burden for medical negligence is best managed by professional liability insurance to provide compensation to the victims. Medical liability regardless of fault is best managed by compulsory medical provider liability insurance with additional medical incidence compensation fund to provide at least a basic level of compensation to the victims. Medical liability without fault is best managed by medical risk relief fund for assistance for the victims. In conclusion, in this paper we analyze various forms of liability and management of medical risks, and propose the use of professional liability insurance for medical injuries with fault, compulsory liability insurance for liability without fault, and relief fund for liability regardless of fault, in the setting of medical incidence. This provides a comprehensive, three-layered solution to the emerging problem of proliferation of medical incident cases in the courts. The first layer is incidence compensation, directed at all medical incidents, via compulsory medical personnel liability insurance regardless of fault. The second layer is risk relief, directed at medical mishaps and medical accidents, via risk relief funds. The third layer is damage indemnity, directed at at-fault liability, via physician professional liability insurance, to fulfill the victims’ damages.

University of Macau / Faculty of Social Sciences. / Department of Government and Public Administration

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