Assessing Factors Influence Outcomes of Disputation of National Health Insurance

• Main Authors: Yu-Ching Chen, 陳玉靜
• Other Authors: Ching-Wen Chien
• Format: Others
• Language: zh-TW
• Published: 2006
• Online Access: http://ndltd.ncl.edu.tw/handle/99830408390464104116

碩士 === 國立陽明大學 === 醫務管理研究所 === 94 === Abstract Every since 1995-03-01 the start of National Health Insurance, the Bureau of National Health Insurance had almost become the monopoly buyer of the medical treatment markets, above 90% hospital revenues come from medical treatment payments of BNFI. Owing to its immense influences on rights, duties, administration procedures and medical treatment behaviors about insured people, insure organization and medical treatment hospitals, there are likely many disputations between them. So the law of National Health Insurance item 5 has proclaimed: ‘to meditate disputation items of insured people, insure organizations and medical treatment hospitals about the appraised cases of insured people, there should set up National Health Insurance Dispute Mediation Committee’, to assert the rights of insured people, insure organization and insure hospitals. After the Global Budget Payment System has been fully carried out, what about the trends of disputation between National Health Insurance and his customers? What about the specific characteristics of these cases and the factors influence the discussion results of disputations? Because medical treatments hold most parts of the disputations, this research focused on medical treatment disputations, cases receipt and settled were from Jan. to Dec. 2004, totaled 40,691. Data analysis of this research was using statistic package software SPSS, represented by number of times, percentage ratio to define class variables; for continuous variables, means, standard deviations, maximum and minimum values and least values were applied to describe and analyze all the characteristics and distributions of the sampled data. Using data exploring software Answer Tree’s Exhaustic CHAID function to classified the researched cases and discuss these factors about which variables may influence the disputation results. From these results, we’ve found the probability of disputation about these data was 1000.44 per million in outpatient services, 6849.80 per million in hospitalizations. The occurrence rate of hospitalization disputation was 68 times than that of outpatient services, and outpatient services disputations were hold 58.4%, higher than that of outpatient services. The were no amount grow up in disputations ince 2004. We think the reasons were the Global Budget Payment System carried out since 2002, it seems to have significance effects in the amounts of disputations, but we still have to investigate it deeply. During 2004, the total amount money of disputations was NTD 190 millions, the minimum disputation money was NTD 1, the maximum disputation money was NTD 2 million. About 49.5% cases whose primitive money were below NTD 500. 18.3% cases got administrative relief payments. Using the kai square inspection of Exhastive CHAID software, the result shows the classes, subjects, money payment of disputation, the grade level of hospitals, the branch bureaus of National Health Insurance, and the positions of mediation experts of Dispute Mediation Committee all have influences on mediation results, but the characteristics of patients (gender and ages) have no influences on these results. According to these results, this research submits some useful referential proposals to health care organization and related person.