臺灣地區外傷事故之健保醫療費用分析：西元1996～1999年

Medical Cost of Trauma under National Health Insurance in Taiwan: 1996-1999

事故傷害所耗用的醫療費用及社會成本十分龐大，國內目前並無有關外傷事故醫療資源耗用之相關研究；因此，本研究之目的為（1）了解85-88年各年度各類外傷事故之住院及門診醫療費用；（2）了解不同層級醫療院所所處理之外傷事故原因及醫療費用申報情形；（3）了解不同層級醫療院所所處理之外傷傷害型態及醫療費用申報情形。本研究之資料來源為國家衛生研究院（國衛院）全民健康保險學術研究資料庫所提供之「外傷」特定主題檔之住院與門診資料。分析結果發現：85至88年因外傷申報之住院及門診醫療費用總額逐年上升，每年之申報總額皆超過百億，到了88年更上漲至2百多億元。以事故之原因分析，各年度住院醫療費用申報額最高之四項依序為交通事故（E47）（29-32億元/年），意外墜落（E50）（13-18億元/年），其他意外（E52）（10-18億元/年），因內科醫療之意外事故、異常反應及後期併發症（E49）（7-17億元/年）；在門診方面，85-88年申報最高之前五項事故是交通事故（6300-9900萬元/年），意外中毒（1200-2700萬元/年），意外墜落（1200萬-2100萬元/年），火及火焰所致之意外事故（E51）（540萬-750萬元/年），其他意外（8600萬-1億元/年）。由傷害型態來分析，各年度住院申報額最高之三項皆同，依序為骨折（A47）（51億-57億元/年）、顱內傷及內傷（A49） （26億-28億元/年）、開放性傷口及血管傷害（A50） （約13億元/年）；門診申報金額最高的一項為其他損傷、創傷之早期併發症（A55） （1.1億-14.4億元/年），申報金額第五位則是顱內傷及內傷。骨折（A47），脫臼、扭傷、拉傷（A48）及開放性傷口及血管傷害（A50）在各年分佔第二至第四高申報額，但每年之高低順序各有不同。以醫院等級來看，住院之申報，區域醫院與地區醫院形式相同，有別於醫學中心；門診之申報則是基層診所有別於另三級醫院。在國衛院釋出健保研究資料檔後，國內算是有一較完整之醫療費用研究資源，然而由於資料建檔之特質，使研究之推估無法更深入，而與其他資料庫之連結分析，應是下一步要努力的目標。

The medical and social cost of trauma is tremendous. However, there was not any study about the medical cost of trauma in Taiwan. The purposes of this study were: (1) to demonstrate the annual insurance cost of different causes and types of trauma in inpatients and outpatients; (2) to show the amount of application fee in different causes of trauma at different accreditation levels of medical institutions; (3) to show the amount of application fee in different types of trauma at different accreditation levels of medical institutions. The data of this study were the “Trauma” files from National Health Insurance Research Database provided by the Bureau of National Health Insurance, Department of Health and managed by National Health Research Institutions. The results showed the insurance cost for trauma increased year by year. It was over 20 billion till 1999. According to the causes of trauma, the top 4 causes of inpatients cost were transport accidents (E47) (2.9-3.2 billions/year), accidental falls (E50) (1.3-1.8 billions/year), other accidents including late effects (E52) (0.1-0.18 billions/year) and misadventures during medical care, abnormal reactions, late complications (E49) (0.7-1.7 billions/year). In the outpatients cost, the top 5 causes were transports accidents (63-99 millions/year), accidental poisoning (E48) (12-27 millions/year), accidental falls (12-21 millions/year), accidents caused by fire and flames (E51) (5.4-7.5 million/year) and other accidents, including late effects (86-100 millions/year). According to the types of trauma, the top 3 types of inpatients cost were fractures (A47) (5.1-5.7 billions/year), intracranial and internal injuries, including nerves (A49) (2.6-2.8 billions/year) and open wounds and injury to blood vessels (A50) (1.3 billions/year); the most cost type of outpatients was early complications of other injuries or trauma (A55) (0.11-1.44 billions/year), the following 4’s were fractures (A47), dislocation, sprains and strains (A48), open wounds and injury to blood vessels(A50), and intracranial and internal injuries, including nerves(A49). The patterns of application of insurance payment in inpatients were same in regional hospitals and local hospitals and different from medical centers. However, in the applications of outpatient’s payment, the pattern of the local medical department was different from the other 3 accreditation levels’ hospitals. Till the release of the research database, the studies about insurance cost for health events may have some reliable resource. However, the accuracy of data should be further improved and the linkage of data of different databanks should be concerned in the next step.