背景與動機：醫療總額支付制度實施後，醫療費用點值為浮動制，使得釵h醫院面臨財務與經營的困難。若醫院能將職業災害醫療申報總費用作合理的歸屬，不但能保有足額的申報費用值，且可減少總額的佔比，提升一般案件的浮動點值，因此職業災害之醫療費用申報極受各醫院所重視。本文以南區某醫學中心導入職業災害個案管理之經驗，落實職業災害醫療申報總費用作合理的歸屬以協助醫療院所提高經營管理之績效。
研究目的：1.探討醫療機構導入職業災害個案管理後申報費用的改變，及職災個案實際的獲利差。2.探討職業災害之勞工有無投保勞保之相關因素，並瞭解無投保之原因。3.瞭解有勞保但未能申請職災的原因。4.提供相關經驗作為醫療機構導入職災個案管理之參考。5.提供相關資訊作為勞工局及勞工保險局導入職災個案管理之建議。
研究方法：1.以個案研究方式探討南區某醫學中心導入職災病患個案管理的過程。2.以申報資料庫分析職災個案管理導入後之成效，並利用無母數Wilcoxon 符號等級檢定分析其績效。3.以面訪問卷調查職災個案特性之分佈，利用描述性統計分析未以職業傷害就醫之因素，並以卡方檢定及t檢定分析有無勞保者之特性差異。
研究結果：職業災害個案管理導入後，該醫學中心職災住院申報總金額有顯著之增加，平均每季增加4,433,607.5元。面訪問卷調查結果顯示，多數職業災害勞工無法符合條件以職災身份就醫的主要原因是無勞保及有勞保但無法以職災身份就醫。職災勞工無勞保的原因又以雇主未替員工投保居多（38.3%），其中營造業職災勞工未投勞保的比例高逹53.8%。而有勞保但無法以職災身份就醫原因則以工作性質與投勞保職災內容不符為最多（51.2 %）。
結論與建議：職災個案管理的導入能有效將職業災害醫療申報總O用作合理的歸屬並提高醫療院所的經營績效。因此建議勞工局及勞工保險局建立職災個案管理窗口，藉由醫療院所的職災個案管理提供通報資源，有效協助管理職災勞工之補償、復健、職能訓練及重返職場等工作，並落實勞工職災的保護補償及其配套措施。 Background and Motivation: Problems with finance and management in many hospitals was caused by the floating-point value of the execution of global budget. If a hospital can make a reasonable medical claim for hospitalized labors with occupational injuries, this proportion will be decreased in the global budget and the floating-point value of general cases will be increased. Therefore, the adequate medical claim is very important for hospital performance management. This study implemented the case management for occupational injury to improve the effectiveness of reasonable medical claim by an example of a medical center in southern Taiwan.
Objectives: This study aims at: (1) examining the change of the medical claim after conducting the case management and exploring the distinguished profit; (2) investigating affecting factors of occupational injury cases between with and without labor insurance; (3) exploring reasons why occupational injury cases with labor insurance were unable to apply for the duty injury; (4) providing information and suggestions for other medical organizations to implement case management for occupational injury; (5) providing information for the Bureau of Labor and the Bureau of Labor Insurance to be engaged in case management.
Methods: (1) The case management was conducted for occupational injury in a medical center; (2) The non-parametric Wilcoxon rank sum test was used to analyze effects of case management; (3) Characteristics of 357 occupational injury subjects were investigated by an interview survey; (4) Frequency tables was used to describe characteristics of subjects; (5) Chi-squared tests and Student’s t tests were used to analyze differences between subjects with and without labor insurance.
Results: In this study, there was a remarkable increase on an average of NT$ 4,433,607.5 per season for the medical claim of occupational injury after the implementation of case management. According to the interview, reasons why subjects cannot be identified as occupational injury cases to make the inadequate medical claim were following: First, the employers didn’t underwrite employee labor insurance (38.3%) for subjects. In the architectural industry, 53.8% of subjects were found without labor insurance in this study. Second, job contents could not meet the demands of labor insurance (51.2%).
Conclusion and Suggestion: The implementation of case management for occupational injury can make the reasonable and adequate medical claim and help medical organizations to achieve effective management. Department of Labor and the Labor Insurance Bureau should establish a duty disaster case management system. In this system, medical organizations should provide case notification, and help cases to deal with compensation, recovery, function training and preparations for returning working places. These efforts should be carried out by the case management to improve health of labors.
