This dissertation studies Oregon primary care physicians' attitudes toward health care reform. Two models of reform are examined: one, health care rationing such as that proposed by the Oregon Health Plan (OHP); and, two, support for national health insurance (NHI). This work examines the necessity for changing the present health care system, traced from the early origins of the medical profession to the present day health care "crisis." The high cost of health care is examined and an overview of the OHP is provided, including citations from John Kitzhaber, M.D., author of the plan. Overall, Oregon primary care physicians overwhelmingly supported health care rationing policies. Just under 75 percent of the physicians expressed support for health care rationing policies such as that proposed by the Oregon Health Plan. However, just under 48 percent of the same physicians expressed support for national health insurance (NHI). Internal medicine physicians were most supportive of health care rationing policies and OB/GYN physicians were least supportive. Conversely, pediatricians were most supportive of NHI and OB/GYN physicians were least supportive. Regression analyses explained 11.5 percent of variation in support for health care rationing policies and 20.9 percent of their support for national health insurance (NHI). While strong support measures were found for health reform such as that proposed by the Oregon Health Plan (OHP), no similar measures of support for NHI emerged. Almost universal support for health care reform such as the OHP was found among primary care physicians across the state, however similar patterns were not found for NHI. It appears from the research's findings that attempts to change the health care system that include the physician's ability to ration care would be more successful than a more systematic change such as would occur under a national health insurance program. This dissertation points out that physicians represent strong supporting forces and/or opposing forces for health care reform. Their attitudes toward such reform must be considered if successful change is to occur in the U.S. health care system.

醫院屬於非營利性機構，不以追求最大利潤為其績效標準，故醫院管理與一般企業管理在本質上便有所不同。在長期觀察醫院的經營情況中，醫院內部長久以來存在於醫療體系與行政體系之間的衝突，成為當今醫院內部重要的管理問題。因此，本研究擬根據醫療體系與行政體系之間的互動情形，歸納出醫院類型的區分構面，希望對於醫院的經營與管理能提供正面而積極的建議。此外，全民健康保險已於民國84年3月1日起正式實施，此一政策對於醫療院所的影響極為深遠，造成台灣醫療生態環境以及醫院管理方式大幅度的改變，並使得業者殷切期盼新的醫院管理之道。 本研究以醫院評鑑等級在地區教學醫院（含）以上的醫院為研究對象。首先透過個案研究，尋找醫院內部互動類型的適當分類構面以及控制機制的選用情形，並提出研究假設。接著再以實證方式，驗證研究假設。經篩選醫院名單後，合格樣本數為112家，回收有效問卷為47份，而檢定結果支持大部分的假設。本研究的具體發現分述如下： 1.醫院可以根據「專業取向」與「行政取向」兩個分類構面，將醫院區分成專業取向較高的「專業取向型」、行政取向較高的「行政取向型」、以及兩者皆高的「互動協調型」三類。 2.互動關係偏向專業取向的「專業取向型」，在全民健康保險實施前，其選用的控制機制，由最高至最低依次為官僚控制機制、文化控制機制、市場控制機制。然而專業取向型醫院在三種控制機制選用之間並無顯著差異，但與其他類型醫院比較，其選用控制機制的絕對值均小於互動協調型。在全民健康保險實施後，其選用的控制機制，由最高至最低依次為官僚控制機制、市場控制機制、文化控制機制。然而專業取向型醫院在三種控制機制選用之間並無顯著差異，但與其他類型醫院比較，其選用控制機制的絕對值亦均小於互動協調型。 3.互動關係最複雜的「互動協調型」，在全民健康保險實施前，其選用的控制機制，由最高至最低依次為官僚控制機制、文化控制機制、市場控制機制，且三種控制機制之間有顯著差異。在全民健康保險實施後，其選用的控制機制，由最高至最低依次為官僚控制機制、市場控制機制、文化控制機制，且三種控制機制之間亦有顯著差異。 4.互動關係偏向行政取向的「行政取向型」，在全民健康保險實施前，其選用的控制機制，以市場控制機制與官僚控制機制同高，其次為文化控制機制，且三種控制機制之間有顯著差異。在全民健康保險實施後，其選用的控制機制，由最高至最低依次為市場控制機制、官僚控制機制、文化控制機制，且三種控制機制之間亦有顯著差異。 由上述研究結果可知，醫院混合採用不同的控制機制。當醫院內部互動關係偏向專業取向時，醫院使用的三種控制機制雖有差異，然其三種控制機制之間的差異並未達顯著水準。當醫院內部互動類型偏向互動協調型時，醫院相對地高度使用標準化的規定與程序，所以互動協調型醫院在官僚控制機制的選用程度上最高。當醫院內部互動類型偏向行政取向時，醫院相對地高度使用可明確衡量的產出，所以行政取向型醫院在市場控制機制的選用程度上最高。 第一章 緒論 第一節 研究動機 第二節 研究問題與研究目的 第三節 研究假定與研究限制 第二章 文獻探討 第一節 醫院概論 第二節 醫院內部互動類型 第三節 控制機制 第四節 醫院內部互動類型與控制機制間的關係 第五節 醫療政策與全民健康保險 第三章 個案分析 第一節 個案研究方法說明 第二節 個案一：甲醫院 第三節 個案二：乙醫院 第四節 個案三：丙醫院 第五節 個案比較分析 第四章 研究方法 第一節 研究架構的建立 第二節 研究變數定義與衡量 第三節 研究假設 第四節 樣本選擇與資料蒐集 第五節 資料分析方法 第六節 問卷的效度與信度 第五章 結果與討論 第一節 樣本描述 第二節 醫院內部互動類型 第三節 醫院內部控制機制 第四節 醫院內部互動類型與控制機制間的關係 第五節 全民健保實施的影響 第六節 假設驗證 第六章 結論與建議 第一節 研究結論 第二節 理論與實務涵義 第三節 後續研究建議 參考文獻 一、中文部份 二、英文部份 附錄 附錄一：醫院起源 附錄二：醫院產品 附錄三：醫院通路 附錄四：醫療品質 附錄五：傳統的醫院分類方法 附錄六：策略觀點的醫院分類方法 附錄七：研究問卷 附錄八：互動類型與權屬別、評鑑等級的關係 附錄九：互動類型與醫院產出的關係 附錄十：控制機制的因素分析 附錄十一：控制機制組合的變化 附錄十二：控制機制的其他影響因素 附錄十三：問卷個別項目分析結果 / Applying control theory, this paper examines the relationship between types of interaction and adoption of control mechanism. After investigating 47 hospitals in Taiwan, we found that there exists strong relationship as described by four hypotheses. Based on “professional orientation” and “administrative orientation”, the hospitals can be classified into three types of interaction, namely, “professional orientation”, “interaction harmony”, and “administrative orientation”. The literature review suggests three types of mechanisms. These mechanisms are market, bureaucratic, and culture control. After empirical survey, this research has three major findings. First, for interaction harmony hospitals, they prefer to adopt bureaucratic control mechanisms, while administrative orientation hospitals prefer to adopt market control mechanisms. As to professional orientation hospitals, there is no significant difference on adoption of three control mechanisms. Second, to compare the intensities of various control mechanisms adopted by different types of hospitals, this study finds that administrative orientation hospital has the highest intensities both on market control and bureaucratic control. As to the adoption of cultural control, there is no significant difference among three kinds of hospitals. Finally, the research finds that the implementation of National Health Insurance has significant impact on the intention of adopting various control mechanisms.

全民健保自1995年施行以來，已成為照顧國人健康最重要的社會安全措施之一，更創造世界各國稱羨的社會健康保險奇蹟。然由於全民健保的保障，使國人忽略平時對個人健康管理之風險控制，因被保險人心理危險所導致之醫療浪費極為嚴重，醫療費用不斷增加，造成健保財務負擔與效率低落，若不進行調整，將危及健保的永續經營。 從社會福利國演進歷史觀之，社會連帶思想與分配正義原則，雖強調人民具人性尊嚴生存之權利及國家之保護義務，但並非單純將個人風險轉由社會共同承擔，而是以國民對於自我社會責任的履行為前提，因天賦或環境等因素，對於無法以自身能力來克服及排除社會風險所帶來的負面影響，使其無法維持「具人性尊嚴之生存」時，始將該風險轉由社會共同承擔，且以保障其基本生活為原則，以求「禁止過度侵害」與「禁止保護不足」原則間之平衡。因此全民健保雖為社會連帶原則之體現，但仍應以個人責任為基礎。 國內外研究皆指出，與個人直接相關之生活型態及遺傳等因素，為影響健康的主要風險來源，醫療服務的影響力約僅佔一成，而加重被保險人責任可有效抑制心理危險因素，透過部分負擔，誘導被保險人重視個人健康責任，以健康之生活型態配合政府之健康檢查與各種篩檢措施，降低罹病率或及早治療，即使不幸罹患重病亦應遵從醫囑，以最經濟的手段達到必要之治療成效。因此，全民健保為達其增進全體國民健康之目的，應以國人之健康風險控制為主，而非將資源過度投注於醫療費用補助，始為根本之道。 反觀我國全民健保，將絕大多數資源用於治療疾病，卻忽略了預防保健的重要性，亦未強調被保險人對自身健康風險之控制責任，近來健保改革聲浪亦多集中於保費收取、藥價、支付制度等議題，忽略個人健康風險控制與心理危險防範之重要性，造成被保險人對個人健康風險控制的不重視，以及預防保健篩檢率偏低、醫療成本負擔逐漸龐大等種種效應。 本文建議，應強化全民健保健康促進功能，免費提供經濟效益高而侵犯性低之預防保健項目，此外，政府應建立重大遺傳疾病通報制度，提供高風險民眾諮詢與檢測等相關服務。再者，健保給付應以基本醫療需求為限，並兼採自負額與共保制，加重被保險人承擔個人健康風險控制責任，且在制度上與社會救助明確區隔，廢除免部分負擔制度，對無力支付部分負擔者改由社會救助支付，以降低被保險人心理危險因素，藉由健康促進之生活方式與配合政府推行保健措施等健康風險控制手段，降低疾病發生率及健康風險損失幅度，始能達成全民健保增進國人健康之目的，並大幅降低健保醫療支出。

台灣地區自民國八十四年三月開始實行全民健保，並於同年七月起提供三十歲以上婦女每年一次免費抹片檢查，但我國婦女抹片檢查利用率和先進國家相比仍舊偏低。爰此，本論文主要目的，在探討台灣地區婦女在健保制度下抹片篩檢利用度的影響因素，藉由實證分析結果，期能提供政府當局有效提高篩檢率的具體方針和建議，以有效降低婦女子宮頸癌的發生率和死亡率。 第二章為理論架構，分別應用Becker(1965)的家庭生產函數和Grossman(1972)的健康需求模型，以建構影響抹片檢查需求的理論模型，並為本論文實證分析的理論基礎。本論文實證分析共分三章，首先利用衛生署國民健康局家庭計畫研究所，分別於民國81年及87年進行的「台灣地區家庭與生育力調查」資料，採用Logit迴歸模型做分析。實證結果發現，抹片檢查接受與否的影響因素在健保實施前後有很大差異，而「南部＊全民健保」及「鄉鎮＊全民健保」的變數對30歲以上婦女亦為顯著正相關；意味健保制度的推行，沖消掉大多數變數的影響效果，使得原本具有影響力的因素變為不顯著，亦即健保政策在婦女抹片防癌使用度的增加有很大貢獻。此外，政府除了對30歲以上女性提供免費檢查給付政策外，亦積極加強衛教宣導工作、建立子宮頸抹片篩檢服務網等工作，使得「全民健保」變數不僅對30歲以上婦女，亦對30歲以下婦女有顯著的正影響力，故建議政府可考慮將篩檢給付擴及至所有已婚女性。 接者，在第四章則利用國家衛生研究院於民國90年所進行的「國民健康訪問調查」資料，應用Bivariate Probit 迴歸模型，並將台灣地區所有316個鄉鎮市分成八個都市化層級，探討都市化程度高低對婦女預防保健利用度之影響。結果發現都市化程度不同，的確造成婦女抹片檢查利用率存在顯著差異，居住在第二至第六個都市化層級的婦女，其接受抹片篩檢的比率明顯較都市化程度最高者低；而第七和第八層級(都市化程度最低)並無顯著較第一層級不願做篩檢。究其原因，乃因政府為均衡不同地區抹片篩檢的可近性，積極鼓勵相關醫療院所加入健保特約醫院，以配合健保給付政策並提供篩檢服務，至民國86年，有超過90%約1500家的醫療院所加入；此外，衛生當局亦在偏遠地區提供巡迴車設站採檢服務，以解決偏遠地區醫療資源不足問題。意味全民健保制度在婦女抹片檢查服務上，已達到提昇偏遠地區醫療服務可近性的貢獻。 最後，在第五章我們利用國民健康局於民國91年所進行的「國民健康促進知識、態度與行為調查」資料，應用兩階段最小平方法(2SLS)估計模型，分析健康資訊對抹片檢查的影響程度。應用Kenkel(1990)衡量資訊的方法，將受訪者對子宮頸癌及抹片檢查相關知識的得分加總，以代表婦女健康資訊程度。實證結果發現，健康資訊的確是影響婦女是否接受抹片檢查的重要因素，擁有愈多相關健康資訊的婦女，因愈了解抹片檢查對預防子宮頸癌的重要，故明顯較願意去接受篩檢。因此，政府除了積極全面衛教宣導工作、建立子宮頸抹片篩檢服務網等工作外，也應針對擁有較低健康資訊的婦女多加宣導抹片防癌的重要性，以有效提高我國婦女的篩檢利用率。 / The National Health Insurance program provided free annual cervical cancer screening for women aged above 30 years old since July, 1995, just four months after the inauguration of the NHI. Therefore, the purpose of this dissertation is to investigate the demand for Pap-smear utilization among women under NHI program. To explore the factors influencing cervical cancer screening and the empirical results can be of great importance to health policy decisions aimed at reducing the incidence and mortality of cervical cancer. In Chapter 2, we attempt to analyze the theoretical foundations applying the household production function developed by Becker (1965) and Grossman’s (1972) health decision-making model and summarize the literatures through a review of the demand for preventive care services. Three empirical essays will proceed in following three chapters. First of all, chapter 3 presents data obtained from the 1992 and 1998 surveys on ‘Knowledge, Attitudes and Practice’ administered by Taiwan’s Provincial Institute of Family, performing a logit model. The results show that factors affecting Pap smear test utilization varied significantly before and after NHI, besides, the coefficient of the South＊NHI and village/town＊NHI interaction variable for women above 30 become significant and positive. This indicates that NHI system plays an important contributor on reducing the disparities in utilization of Pap smear tests between different areas. In addition to NHI coverage, other strategies such as strengthening educational activities and establishing a service network for Pap-smear screening are other vital contributors to increase the utilization rate of Pap smear screening for those aged below 30 years under NHI. To further increase the utilization of cervical cancer screening, the insurance coverage could be extended to all married women regardless of age. In chapter 4, we attempt to explore the impact of urbanization level on the use of female preventive services under NHI, using a bivariate probit model and dataset obtained from the 2001 National Health Interview Survey provided by the National Health Research Institutes. All 316 cities/counties in Taiwan was stratified into 8 levels of urbanization. The results showed that urbanization levels have a significant influence on Pap-smear screening. Those living between the second and sixth levels of urbanized regions were significant negative to the cervical cancer screening compared to the highest urbanization level. In order to balance the accessibility of cervical cancer screening between different areas, the health authorities encourage the obstetric, gynecological hospitals and clinics to contract with the government, more than 90%, about 1,500 medical care institutions were under contract until 1997. Besides, government authorities introduced mobile testing stations to provide specimen collection services in the deeper remote regions. As a result, those living in the areas with the 7th level and the 8th level (the lowest level) of urbanization were not less likely to take Pap-smear test. It means that the implementation of NHI has enhanced the accessibility of taking pap-smear test. Finally, in chapter 5, the nationwide survey dataset was obtained from the 2002 Health Promotion of Knowledge, Attitudes and Practice (HPKAP) in Taiwan, provided by the Bureau of Health Promotion and two-stage estimation model was adopted to investigate the association of cervical cancer screenings with the healthcare information. The results showed that women’s healthcare information has a significant positive effect on the utilization of cervical cancer screening; that is, the more informed women are, in terms of information and knowledge on cervical cancer screening, the more likely they are to undergo Pap-smear testing. Therefore, it is important for the healthcare authorities to place greater effort into strengthening the knowledge and information on cervical cancer screening and Pap-smear testing, for those who are currently less informed, so as to enhance the overall efficiency of the screening program.

我國全民健康保險政策是屬於社會保險，早期在推行健保時決策模式是傾向國家主義，然而隨著民主化時代的來臨，人民權利意識抬頭，各種利害關係團體相應而生，因此民主治理變成重要的課題。在重要政策參與中各個利害關係人皆希望能夠被納入決策。我國目前健保政策體制內的參與管道最主要為費用協定委員會及監理委員會，主要監督及決定健保預算分配，這兩會在2013年整併為健保會。不論整併前後，委員會基本上是以統合主義的精神運作，邀進行決議，最大的優點在於能夠藉由與多方政策利害關係人的溝通，凝聚社會共識。然而哪些團體能夠代表參與政府制定決策的過程，參與的代表能否充分表達團體的意見？因此代表性正是統合主義中最具爭議的，故如何找出遴選團體的標準是刻不容緩的。 　　本文嘗試以社會統合主義的觀點，套用在健保會運作上。然而社會統合主義要運作的良好，基本上必須要在水平及垂直方面的機制建構完善，垂直層面必須要各級組織匯集各級團體的意見，並由代表進入水平的平臺進行協商；而在水平溝通平臺上也需要各方代表皆能有平等及有效的決策。本文最主要了解的是垂直面的整合情形，亦即這些被派入健保會的政策利害關係團體代表是否有充分的被賦權，在會中討論的結果能否充分落實，因此要衡量團體內部本身的治理。本文欲透過專家座談建構組織內部運作的指標，建構指標測量健保會內部實際運作情況，對於好的健保會參與組織建構初探性的評估。希望未來能夠作為健保會遴選組織進入委員會的參考依據。 / National Health Insurance (NHI) policy is a part of social insurance in Taiwan. In the early stages of the program, the pattern of decision-making tended to be based on a Statist model, but as Taiwan democratizes, citizens and various interest groups have become increasingly aware of their rights. Therefore, the democratic governance of National Health Insurance policy has also become an important issue, as stakeholder groups all hope to be included in the NHI’s decision making process. In Taiwan, the two main participation channels within the system are the Medical Expenditure Negotiation Committee and the Supervisory Committee. The main missions of these two committees are to control health care costs and to allocate medical resources. In 2013, these two committees were merged to form a single National Health Insurance Committee. Whichever their merger status is, the committees basically function according to the principles of Corporatism, whereby peak-level organizations are invited to take part of the committee’s decision-making processes. The biggest advantage of the merger is that the committee would be able to achieve social cohe-sion and consensus through its direct communication with various policy stakeholder groups. But the problem with this arrangement is the following: Which groups can participate in the government’s decision-making process? Can the representatives fully express the views of their respective groups inside the committee? Therefore, the question of representation is the most controversial issue in Corporatist theory, and it is imperative to develop the proper criteria by which major interest or corporatist groups are selected. This study attempts to observe the National Health Insurance Committee from the perspective of social corporatism. For social corporatism to function well in society, basically both its horizontal and vertical mechanisms have to work perfectly. Vertically, groups must be able to amass and integrate the views of their sub-organizations at all levels; horizontally, the group’s representatives must all have equal capacity to make effective decisions. This paper will focus on understanding the vertical dimension of social corporatism, which means asking the following questions: Can/do the representatives fully and adequately represent their group? And whether the outcomes discussed at the committee meetings are fully implemented? To answer these questions it is thereby necessary to measure the internal governance of the groups themselves. This paper will examine various internal operating indicators developed through experts’ panel discussions, with the primary objective of determining good committee participation measures. It is hoped that the construction of these internal governance indicators will serve as the criteria by which future corporatist groups or stakeholder organizations are selected into the National Health Insurance Committee

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.

全球每日產出的資料量持續成長，龐大的資料量、雜亂的資料檔案格式造成資料處理的困難；此外，全球智慧型手機的出貨量持續上升，未來將會至少人手一台行動裝置，同時行動網路的效能提升將可負荷更多的資料流量，行動工作者的數量也因此逐年增加。對商業智慧系統而言，透過企業資料的分析可以發現資訊之間的關連與隱藏其中的事實，讓使用者掌握更多的知識用於決策，分析的資料來源越豐富，其可提供做為決策用的訊息就更為準確。 　　過往商業智慧透過關聯式資料庫處理資料來源及電子郵件的通知使用者，但是龐大的巨量資料遠超過前者所能有效處理的數量，進而造成對資料擷取、保存、使用、分享以及分析時的處理難度；後者對於外出的使用者來說，電子郵件僅只是收到通知而已，使用者依然得需要電腦才能觀看分析報表。 　　故本研究使用雲端運算分散儲存及運算的技術及行動裝置隨手可得的特性解決前述的兩個問題，先透過雲端資料庫加速處理巨量資料的存取並製作成資料倉儲供商業智慧使用，接著透過行動應用程式即時接收推播訊息並呈現分析報表於行動裝置上。 　　在實作中，利用非結構化資料庫進行資料的存取，比起過往的關聯式資料庫確實可以有效提升巨量資料處理的速度；透過行動裝置的報表呈現，在平板電腦有較佳的成效，在手機上則是因為螢幕大小的關係，畫面呈現效果較差，這方面則有待改善。 　　本研究透過非結構化資料庫及行動應用程式設計新的行動商業智慧解決方案，實作雛型系統，並且透過異常申報健保費用醫院為案例，進行系統整體的測試，證明其架構及運作模式之可行性。經過驗證，本系統將能提供使用者使用巨量資料做為分析數據，並且透過行動應用程式立即取得分析報表。 / The volume of daily output data continues to grow world- widely. The huge amount of data and the disorder of data format cause the difficulty of data processing. Additionally, the number of smartphone sales is continuously growing, so everyone will own at least one smartphone in the future. In the meantime, the effectiveness of mobile internet and wireless is largely improved, so it can be loaded with more data flow. Because of this phenomenon, the number of mobile workers will be increasing per year. For business intelligence systems, through the analysis of enterprise's data we can find the relevance and facts hidden in information, allowing users to acquire more knowledge for decision-making. The more data sources we analyze, the more accurate information can be used to make decision. 　　In the past, business intelligence processes data sources through relational database and uses e-mail to notify users. However, the huge amount of data exceeds the number that can be effectively processed by relational database. On account of this, it becomes difficult regarding data acquisition, storage, application, sharing, and analysis. As far as the users are concerned, they only receive notifications by emails, so they still need a computer to view the analysis report. 　　In this study, I use cloud computing technology and mobile devices to solve the two aforementioned issues. First, we speed up the process of big data in data acquisition through Hadoop Hbase, and made it into data warehouse for Business Intelligence use. Secondly, we use mobile applications to receive push messages instantly and present analysis reports. 　　In the practical work, I use NoSQL database to acquire and store data. Compared with relational database, we can indeed effectively enhance the speed of big data processing. In reports’ presentation on mobile devices, the Tablet has better user experience then the phone. The phone is displayed comparatively poorly because of its small screen. This part needs to be improved. 　　In this research, I conceive a new solution of mobile business intelligence through NoSQL database and mobile applications, and implement this method into a prototype system. Moreover, through an example of the analysis of hospitals which have anomalous health-insurance reporting expenses we can test the whole system. It proves that this system’s structure and the mode of operation are feasible. The system will be able to provide big data as the source of analysis and present reports immediately through mobile devices to users.

我國健保費用逐漸增長，進而衍生出許多健保問題，其中浮報、虛報及詐欺等三種情況，會造成許多醫療資源的浪費。然而，目前電腦檔案分析只能偵測出浮報、虛報的行為，無法偵測出詐欺情況。對於健保詐欺之偵測只能仰賴傳統隨機抽樣檢驗及人力分析，而我國健保平均一年門診審查申報量約3.5 億件，其人力的負擔非常沉重。故本研究將探討如何利用電腦工具初步判別醫事機構之費用申報情況。 本研究透過大量文獻回顧，發現美國有研究指出結合Benford’s law 與智慧型方法來進行詐欺偵測，可獲得很好的效果(Busta & Weinberg 1998)。Benford’s law 指出許多數據來源皆會呈現特定的數字頻率分佈，近年來Benford’s law 亦被應用在許多不同領域的舞弊或詐欺的審查流程中。 本研究使用Apache Hadoop 及其相關專案，建構出一個大量資料儲存分析之環境，針對大量健保申報費用資料來進行分析。此系統結合了Benford’s law 數字分析方法並運用支持向量機(Support Vector Machine)來對健保費用申報進行大規模電腦初步審查，判別該醫事機構是否有異常申報之情況發生，並將初步判別之結果提供給健保局相關稽查人員，進而做深入的審查。 本研究所建構的智慧型健保費用異常偵測模型結合了Benford’s law 衍生指標變數與實務指標變數，並利用SVM 分析健保申報費用歷史資料，產生出預判模型，之後便可藉由此模型來判別未來健保費用申報資料是否有異常情況發生。在判別異常資料方面，本研究所建構的模型其整體正確率高達97.7995%，且所有的異常申報資料皆可準確地預測出來。 因此，本研究希望能結合Benford’s law 與智慧型運算方法於健保申報異常偵測上，如此一來便可藉由電腦進行初步審查，減少因傳統隨機抽樣調查所造成的不確定性以及審核大量健保資料時過多的人力資源浪費。

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.

我國每十年進行一次人口普查，以取得國人經常活動地區的資訊，作為中央及地方政府政策規劃的參考。然而，十年一次的人口普查無法即時反映各地區人口特質及其活動，隨著普查完訪率逐年下降、個人資料保護法意識抬頭等趨勢，普查的涵蓋率及其資料品質愈加受到質疑，近年各國思考以其他資料蒐集方式取代傳統普查。我國實施全民健康保險制度已逾20年，民眾納保率超過99%，因此本文以全民健保資料庫為研究素材，透過個人就醫行為探討國人經常活動地區，透過剖析各種疾病的就醫行為，可作為政府評估醫療資源規劃的參考。 本文以全民健保資料庫為依據，探討我國國民選擇醫療地點的特性，作為經常活動地區（或是常住地）的輔助參考。過去研究大多利用上呼吸道感染（俗稱感冒）作為估計常住地的依據，但每年平均只有接近70%國人會因感冒而就醫，其中青壯年、老年人因感冒而就醫的比例明顯較低，以此作為常住地的估計基礎恐有涵蓋率不足之虞。本文依據健保資料庫中的2005年百萬人抽樣檔，包括就醫門診處方及治療明細檔(CD)、承保資料檔(ID)等資料，比較數種常住地判斷的參考準則（包括感冒就醫），分析各方法所觀察到資料的特性及限制，評估以這些準則作為判斷常住地的可行性。 結論：本文提出除了感冒就醫之外的三種常住地推估準則，分別為：因為感冒或是消化就醫、單次健保補助金額較低、基層院所就醫。以樣本涵蓋率量而言，三種準則都能改善感冒就醫涵蓋率的不足，其中以單次金額與基層院所就醫的樣本數增加最多。另外，如果與所有門診資料、普查資料的人口資料比較，發現單次金額與基層院所就醫推估的人口年齡結構最為接近，但單次金額的縣市（地區）結構與普查資料的差異較大。 限制：受限於青壯年人口就醫率較低，本文提出的幾種常住地判斷準則在20歲至44歲的涵蓋率仍然偏低，建議未來研究可經由權數調整修正樣本的年齡等人口結構及比例，或是仰賴就醫以外的紀錄推估，但須考量資料串連及品質等問題。 / Many countries conduct population census every 10 years to acquire the information of population structure and its trend, but the information is not likely to updated since the 10-years period is usually too long. Moreover, the low response rate of questionnaire and the enforcement of Personal Information Protection Act further jeopardize the population census and many question its data quality. Thus, quite a lot of countries are seeking alternatives for collecting the information of de jure population, replacing the regular population census. In this study, we explore the possibility of using the data from National Health Insurance (NHI) Research Database for acquiring the information of de jure population in Taiwan. Taiwan started the NHI in 1995 and more than 99% of Taiwan population are covered. Since the medical accessibility created by the NHI, Taiwan’s people tend to visit medical institutions near to where they live, when they have minor diseases. Past studies showed that the upper respiratory tract infection (or cold) is a popular choice of minor diseases. We will evaluate if the cold is a good candidate and propose alternative criteria for the definition of minor diseases. We found that the proportion of populations with upper respiratory tract infection is about 70% and it is age dependent, with the elderly the lowest. On contrary, the records of smaller amounts and the records of physician clinics (or general practice clinics) can cover more than 90% population, much better than the records of upper respiratory tract infection. The records of digestive system diseases and upper respiratory tract infection can also increase the coverage of elderly population. We recommend using the medical records of smaller amounts to acquire the de jure population.