應用資料探勘探討門診高就診次者特性之研究

Applying Data Mining to indicate the characteristics of outpatients with high consumption of medical resources

我國自1995年實施全民健康保險，截至2002年其納保率超過98%，顯示台灣已邁向「全民皆保」之境界。然而佔全體被保人中僅1%的人即耗用健保資源的27.7%，再者，國人每年平均就醫次數在14次以上，相較於OECD實施健康照護系統之成員國家的平均5.9次，顯然偏高。因此本研究之目的為：探討高門診診次者的屬性與其高就診行為存在的關聯或規則，進而有效的管理醫療資源。研究方法為資料探勘法，首先經由文獻探討擷取有關可能影響高門診醫療資源使用之因素，針對中區健保局門診就醫申報資料中，選擇可取得資料屬性，透過資料探勘方式，探索各資料屬性與就醫診次之間的關係，排除就醫次數大於101次多屬道德危害或全民健保包醫制者，研究結果呈現高就診次之男性較女性有向高年齡層集中之現象且人數較多；以職業別而言，「證券期貨及其他金融業」的保險對象有使用門診醫療資源過多的傾向。本研究結果可提供相關單位，進行醫療資源高利用保險對象輔導計畫或對策之參考。

Since 1995, Taiwan government has launched the national health insurance policy which covered 98% of the population in 2000. However, 1% of the insured consumed 27.7% of the entire medical expenditure. Meanwhile, the average number of outpatient visits was more than 14 times per insured per year, which is much higher than the average in OECD countries of 5.9. The purpose of this study is to identify the relationship between the attributes of those heavy insurance users and their behavior of medication consumption to better control the medical resources. The research methodology is data mining which started from literature reviewing to select factors that influence outpatients on high usage of the medical resources. The target databases containing outpatients’ reimbursement records are used to select the necessary attributes of the data for data mining, through which we probe into the characteristics of outpatients with high usage of medical resources and the correlation or rules related to their medical care seeking behavior. Excluding those with outpatient visits more than 101 times per year, which related to welfare loss or illegal issues, the results of the research show that men with high outpatient visits more focused on the old-age group than women, and the number of men with high outpatient visits is more than that of women. Regarding professions, employees in financial organizations tend to consume more outpatient resources. The results for this study can be used as reference for government’s plans or polices making to further counsel the group of outpatients with high usage of medical resources.