最佳適合保險費率模式之建立及推估未來15年全民健保財務收支

Establishing Optimum Premium Prediction Model and National HealthinSurance Financial Revenue and Expenditure

10.6288/TJPH2003-22-01-06

蘇喜(Syi Su)；蕭世槐(Shih-Huai Hsiao)；莊逸洲(Yi-Chow Tsung)

全民健康保險 ； 費率 ； 醫療費用支出估 ； Health Insurance ； Premium ； Medical Expense ； Predication

台灣公共衛生雜誌

22卷1期（2003 / 02 / 01）

43 - 54

繁體中文

目標：本研究以全民健保實施以來之經驗資料，根據經驗及文獻資料建立醫療費用支出及保費精算樣式，並根據經驗資料配合各項精算假設，利用此模型在各項精假設，利用此模型在各項假設組合之下精算未來15年全民健康醫療支出與保費費率。方法：本研究為一橫斷性研究，以全民健保自實施以來之經驗資料，經由支出面詳細分析其各年齡別及性別之住院利用、手術利用、急診利用、中醫、西醫、牙醫門診利用模式等，並以人口成長趨勢作為以上各種醫療費用支出及保費收入之客觀估計。結果：根據本研究結果，醫療總支出在2001年達到3,568億元，健保費率將在2005年達到法定之6%上限。在各項影響因素中，以利用率變化之影響最大。以平均眷口數0.88人、醫療費用成長率為10%為例：在利用率成長為2%時，2003年即可超過法定上限。結論：本研究於受限於以1996、1997年全民健康保險醫療利用資料來推論未來15年的健保費率與醫療費用支出，本研究預估之準確性可能會受到中央健保局是否採取能抑制利用率上升各類措施及民眾就醫行為改變之影響，此部份之準確性仍待時間的驗證。惟本研究以各年齡別及性別之住院利用、手術利用、急診利用、中醫、西醫、牙醫門診利用率等六個因素所建立之費率與醫療費用支出預測模型，可提供相關單位依據實際所需，擬定各種不同的假設後，投入該模式，即可推算出未來收支及保險費率，此為該模式最大貢獻。

Objective: This study set up the actuarial model to estimate the reasonable annual premium rates within fifteen years from 200 I, based on the assumptions according to several empirical experiences and references. Method: This is a cross-sectional study. The premium and medical expense models were established by incorporating the empirical data such as inpatient care, surgical operation services, outpatient care, ambulatory care, Chinese herb medicine, dentistry, and several assumptions under adjusted gender and age, and population growth trend. Result: The result showed that the total medical expenditure would be over 356.8 billion NTD in 2001 and the premium rate would exceed the 6%,according to the criteria of adjustment of premium rate empowered by the National Health Insurance Law, in 2005. Besides the average number of dependents is assumed to be 0.88 from March, 1998Law, in 2005. Besides the average number of dependents is assumed to be 0.88 from March, 1998onward, health care expenditure increases at rates 10%, the premium rate would exceed 6% in 2003.Conclusion: The research has covered two years' empirical data since the implementation of the National Health Insurance Program, the precision rate of predicting premium rate and medical expense in 15 years from 2001 may be effected by the NHl's medical expense control approaches and changing of people's utilization behaviors. It still needs some time to improve. In brief, the contribution of the prediction model of premium and medical expense models could provide to calculate the medical expenses and receipts based on different assumptions by administration unit and researcher. (Taiwan J Public Health.

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