全 民 健 康 保 險 年 報
National Health Insurance In Taiwan
2013-2014
ANNUAL REPORT
門診高利用輔導展現成效
自
2001
年起實施「全民健康保險門診
高利用保險對象輔導專案計畫」，掌握門
診高利用保險對象醫療資源利用情形，輔
導正確就醫，杜絕醫療浪費。
2010
年起，
門診高利用保險對象定義為全年門診申報
就醫次數超過
100
次者，自
2013
年起更
擴大輔導範圍，將
2012
年度門診就醫次數
超過
90
次（不含重大傷病患者）之保險對
象納入輔導。
Counseling Effective
in Reducing Excessive Utilization
Since 2001, the NHIA has operated a program to track
and counsel individuals who make an excessive number of
outpatient visits. The program prevents medical waste by
guiding these heavy users of medical resources on how to
properly seek treatment. Beginning in 2010, a “heavy user”
subject to counseling was defined as an individual who made
more than 100 outpatient visits a year. The definition was
broadened in 2013 to those whomade more than 90 outpatient
visits in 2012 (not including those with catastrophic illnesses).
3.
健保署各分區業務組依轄區特性，就高
利用及高費用醫療項目，如電腦斷層
掃描攝影（
CT
）、
核磁共振掃描攝影
（
MRI
）、
體外震波碎石術（
ESWL
）
等，
利用檔案分析建立監測指標，以篩選異
常院所或醫師，加強審查管理及輔導。
2.
Inviting medical representatives to participate in identifying
indicators that can detect abnormalities and make use of
claims data to review medical institutions’ diagnosis and
treatment practices. These indicators, which all have specific
thresholds that signal abnormalities, are used in automated
procedural reviews and help save on manpower used in
professional reviews.
3.
Having branches of the NHIA use profile analysis to
develop region-specific indicators that work best in
monitoring the use of high-utilization, high-cost devices,
such as CT-scans, MRIs and ESWL, in their jurisdictions
and detecting abnormal usage patterns among individual
medical institutions or physicians.