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.

本文對重大傷病的醫療成本推估進行研究，并以癌症為例，利用台灣癌症中心及健保資料庫數據對其成本進行討論。分別對男性及女性罹患率最高的前十大癌症的發生率、首年生存率、持續生存率、原位癌的罹患率進行討論。 文中将醫療科技發展對於原位癌及早期癌症檢測對保險承保範圍及理賠產生的影響進行討論，並且以各個國家地區的重大傷病保險在早期治療過程中是否納入承保範圍進行歸納。本文以台灣的數據討論了乳癌原位癌及子宮頸原位癌的罹患狀況，并考慮時間趨勢下推估其醫療保險成本。 / This paper will study the cost of catastrophic illness. The paper will use the data from Taiwan Cancer Registry and Nation Health Insurance Research Database to examine the cost of cancer insurance. With the use of these data, we will look into factors such as sex, the highest prevalence rate of the top ten cancers, first-year survival rate, survival duration, and carcinoma in situ of the prevalence. This paper will also look into the effect of the insurance coverage because of the development of medical technology, and compare and contrast with laws and insurance’s terms of different countries. This paper will use Taiwan’s data to discuss the incidence rate of carcinoma and cervical carcinoma in situ, and research the time trend of the insurance cost.

近年來，隨著我國國民的壽命持續增長，人口老化愈加明顯。預期臺灣在2021年將進入人口零成長，2025年65歲以上人口比例也將超過20%（來源：國家發展委員會2014年人口推估）。人口老化帶來許多問題，如老年生活、醫療、以及長期照顧等需求，其中照顧需求與年齡正相關，預期需求將隨壽命延長而增加，需要及早規劃及因應，這也是今年通過長期照護法的原因。由於各國國情不同，對於長期照護的定義、補助及需求也不盡相同，有必要發展適用於臺灣特性的，推估長期照顧需求的所需之資源。重大傷病中的許多疾病與失能、甚至長期照護有關，由於全民健保實施至今已逾20年，重大傷病的認定標準及程序相對客觀、中立，受到民眾、學術、政府各界肯定。 有鑑於此，本文以全民健保資料庫的重大傷病資料庫為基礎，挑選八類引發長照的重大傷病，作為規劃長期照護保險的參考。本文以這些傷病的發生率、罹病後死亡率、罹病後存活率等，結合國發會所人口推估的結果，利用年輪組成法(Cohort Component Method)推估長期照顧的未來需求。研究發現：未來需求人口從2013年約10萬人，迅速增加至2060年的21萬人，增加速度相當快。而參考「長期照顧保險法」草案的給付內容，若聘請一名外籍看護每月20,000元計算，每人分擔將從2012年的$530元/月升至2060年的2,728元/月；若不調整保費且以隨收隨付計算，每人每月繳交400元長照保費，長照給付將從2012年每月13,353元降至2060年每月3,556元，由此可知壽命延長、人口老化將造成長照保險的財務問題。另外，本文考量的八項重大傷病較為保守，沒有加入老化、遺傳等因素的長照需求，預期將不足以因應實際需求，未來有必要引入商業保險來彌補社會保險的不足。 / In recent years, with the sustainable growth of the life expectancy in our country, population aging becomes more apparent. Taiwan’s population of ages 65 and over will exceed 20% within 10 years, before 2025. (Source: National Development Council - Population Projection on 2014). The population aging an prolonging life incurs a big demand for caring the elderly, such as the economic need after the retirement, medical cost, and long-term care. Among these needs, the demand of long term care was under-estimated and is only recognized recently. Thus, this study focuses on predicting the need of long-term care in Taiwan. Specifically, the definition and standard (as well as types and amounts of subsidy) for juding whether one needs long-terma care is not yet determined, although Taiwan’s government passed the long-term care law (Long-Term Care Insurance Law) earlier this year. We should adapt the notion of catastrophic illness (CI) and use certain CI categories, which are related to long-term care, to design the long-term care insurance. Catastrophic illness (CI) is one of the key features of Taiwan’s National Health Insurance (NHI), and the definition and process of evaluating if one is with the CI is quite complete. We choose eight categories of CI and use the NHI database to obtain their incidence rates, mortality rates, and survival probability. Together with the population projection from National Development Council in 2014 and the cohort component method to predict the long-term care demand in Taiwan. The syudy result shows that the population needing long-term care will rise from about 100 thousands in 2013 to about 210 thousands in 2060. Moreover, if the long-term care insurance is funded via pay-as-you-go, the individual premium required will rise 5 times from 2012 to 2060. This indicates that the long-term care might be too expensive and the commercial insurance can play an important role as a supplement.

重大傷病是我國全民健康保險的重要特色之一，透過社會保險的風險分擔機制，病患享有免部分負擔等優惠，降低因為罹病帶來的財務負擔，但重大傷病同時也成為全民健保的主要支出項目。民國102年領取重大傷病證明者不過98餘萬人（約總人口的4%），但其一年的醫療費用多達一千五百多億元（接近總支出的27%），平均每位重大傷病患者的醫療費用約為平均值的7.34倍，其中癌症又是重大傷病中人數最多者，大約佔了49%（資料來源：衛生福利部中央健康保險署）。因為許多重大傷病的發生率、盛行率與年齡成正比（黃泓智等人，2004），未來隨著人口老化，全民健保支出也將跟著上升。 　　本文使用全民健保資料庫，探討近十年重大傷病（尤其是癌症）趨勢，估計重大傷病的年齡別發生率、死亡率，評估人口老化對全民健保造成的影響，其中承保資料檔（ID）、重大傷病檔（HV）為本研究主要的依據資料。而由於健保資料庫的資料種類及數量龐雜，在初期資料的偵錯及處理上非常重要但也相當費時，至於發生率、死亡與否的判斷亦十分棘手，因此過程中我們將一一說明資料分析步驟及注意事項。本文發現癌症及重大傷病的盛行率逐年上升，但發生率並沒有明顯變化，加上近年癌症死亡率幾乎不變（但台灣全體國民的死亡率逐年遞降），因為台灣的人口老化，預期未來罹患癌症人數會逐年增加，癌症將繼續蟬聯十大死因之首，但罹癌死亡率的下降也可發現近年醫療進步所造成的影響。此外，我們也考量隨機死亡模型（Lee-Carter Model），發現無論是癌症死亡率、或是罹癌死亡率都有不錯的估計結果。而在文末也提出癌症病患的就醫行為以供後續研究者參考。 / Catastrophic illness (CI) is one of the key features of Taiwan’s National Health Insurance (NHI). Through risk-sharing mechanisms of social insurance, it can reduce the financial burden of the CI patients since treating the CI is usually expensive. However, the CI also becomes a major expenditure item of NHI. The people receiving the CI card are just 0.98 million in 2013 (about 4% of the total population), but their smedical costs are over 150 billion NT dollars (nearly 27% of total expenditures). The average medical cost per CI patient is about 7.34 times of the national average. (Source: Department of Health and National Health Insurance Agency). Because the incidence and prevalence rates increase with age (Huang et al, 2004), the total NHI expenditure is expected to increase in the future due to population aging. This study intends to use the NHI database, including the records of personal identification and out-patient visit from all CI patients, to explore the incidence and mortality rates, for example, of CI patients. Because the NHI database is big and messy, we shall first debug and clean them. Also, since the death of CI patients are not fully reported in the NHI database, we propose a method to identify the deaths and use the official statistics to evaluate. The results show that the prevalence rates of all CI increased every year, but their incidence rates did not change significantly. The mortality rates of cancer patients also did not change much. Based on these findings, we expect the proportion of CI patients and their size will continue to grow. In addition, we applied the Lee-Carter model to the cancer mortality rates, and the fit is pretty good.

政府為促進國人健康,並以社會保險的形式分攤弱勢團體的就醫需求,於民國84年開始實施全民健康保險,實施至今超過20年,而且納保率已高達99%。重大傷病證明是全民健保的主要特色之一,持有重大傷病證明卡的病患就醫時可免除部分負擔,減輕罹患重病患者的醫療負擔。截至106年2月約有4%國人領有重大傷病證明卡,但其醫療費用佔健保支出超過 27%,預期這兩個數值會因人口老化而逐年上升,使得重大傷病的相關議題越來越受到重視。 本文以全民健保資料庫中的重大傷病證明明細檔(HV)為基礎,以2005年百萬人抽樣檔之承保紀錄檔(ID)、門診處方及治療明細檔(CD)及住院醫療費用清單明細檔(DD)輔助,探究罹患重大傷病發生及死亡議題,提出判定發生、死亡的準則,並且依此分析各種疾病發生率與死亡率的關係。另外,本文也使用資料庫內容驗證重大傷病患者與非重大傷病患者之間醫療費用的差異,研究也發現新發生的病患就醫率偏低,並以國際疾病分類代碼驗證重大傷病門診處方及治療明細檔(HV_CD)資料抓取的準確性。 / Taiwan started National Health Insurance (NHI) in 1995, for more than 20 years, and more than 99% people are covered in this social insurance plan. It is believed that the NHI has further enhanced the health of Taiwan’s people.Catastrophic illness(CI)card is one of the key features in the NHI and people with this card can enjoy waiver of copayment and other medical benefits which reduce the financial burden of CI patients. For example, about 4% Taiwan’s population were with the CI card and they spend more than 27% of total medical expenditure of NHI. Since the probability with CI increases with age, the population aging and prolonging life are expected to worsen the financial burden of the NHI. Our goal is to explore the medical need and its trend of CI patients, via the data from the NHI Database, including Registry for catastrophic illness patients(HV), Registry for beneficiaries(ID), Inpatient expenditures by admissions(DD)and HV’s Ambulatory care expenditures by visits(HV_CD). Since the medical records do not cover all the required information, we propose several criteria for data analysis, such as the rules of judging whether the patients incur CI and the CI patients passed away. We found that the incidence rates and mortality rates of CI patients decrease with time. Also, there are questions about the data quality regarding the HV_CD database and more than 50% new CI patients do not have medical records of CI diseases.