職業病疾病負荷與醫療成本推估：以職業性呼吸疾病與石綿相關疾病為例

Abstract

背景：台灣職業健康保護與先進國家相比較為薄弱，職業傷病問題普遍，實際獲得認定和補償的職災勞工卻不成比例，顯示職業傷病嚴重低估。職災醫療由健保先行支付，再由勞保職災保險償付，因此低估現象將導致醫療成本由勞保轉嫁健保。呼吸疾病及石綿相關疾病常具有多病因性、潛伏期長的特性，增加其認定為職業相關的難度；然而其整體疾病負荷及醫療支出驚人，探討其可歸因於職業因素的比例，有助於認識台灣職業傷病低估的嚴重程度。 方法：本研究運用各職業因素的暴露盛行率和相對危險性計算呼吸疾病及石綿相關疾病的「人群可歸因百分比」，藉此推估健保資料庫中2005、2010、2015三年的就診人數及給付費用中，可歸因於職業因素的疾病負荷與醫療成本規模，並與職災醫療實際給付的數據比較。 結果：本研究推估，2015年罹患職業性呼吸疾病及石綿相關疾病的職災勞工共約1.5萬人、耗費醫療成本近3億元，而職災醫療實際給付則不滿2百人、核付金額約3百萬元，兩者落差近百倍。 結論：為改善職業性呼吸疾病及石綿相關疾病等職業傷病的低估問題，本研究建議，政府應促進職業暴露評估的頻次及品質，並建置完整的暴露資料庫。在制度面，應簡化認定程序，暢通轉銜職災醫療的管道，並釐清職災醫療的定位，以增進職災醫療利用率、合理化職業病醫療成本的分佈。對於潛伏期長、暴露證據蒐集困難的疾病，可考慮放寬認定標準，並針對高風險職業強化在職及退休後的健康檢查。透過教育宣導增進社會對職業傷病的警覺，亦是不可或缺的策略。

Background: The occupational protection system in Taiwan is weaker than in advanced countries, and problems of occupational injuries and diseases are more prevalent. However, recognized and compensated cases of occupational accidents are disproportionately few, indicating severe under-estimation of occupational injuries and diseases. Since the expenses of medical treatment for occupational accidents are paid by the National Health Insurance (NHI) in advance and reimbursed afterward by the Workers’ Compensation Insurance (WCI), under-estimation would cause cost-shifting from WCI to NHI. Respiratory diseases and asbestos-related diseases are featured by their multi-etiological nature and long latency periods, adding to the difficulties in recognizing their work-relatedness. Due to their heavy overall disease burden and high healthcare spending, examining the fraction attributable to occupational factors of respiratory diseases and asbestos-related diseases is helpful in understanding the magnitude of under-estimation of occupational injuries and diseases in Taiwan. Methods: Prevalence rates of various occupational exposures and relative risks of these exposures for respiratory diseases and asbestos-related diseases were used to calculate population attributable risk percentages (PAR%), with that the numbers of visiting and amounts of payment attributable to occupational factors were estimated. The estimates were compared with the data of actual payment for medical treatment for occupational accidents. Results: It is estimated that about 15 thousands of workers suffered from occupational respiratory diseases and asbestos-related diseases in 2015, costing 300 million NTD. In contrast, less than 200 cases were approved in the same year, and the actual WCI payment was 3 million NTD. There was a 100-fold gap between the estimates and the actual payment. Conclusion: To increase the recognition of occupational respiratory diseases and asbestos-related diseases, we suggested that the government should facilitate the frequency and quality of occupational exposure assessment and construct comprehensive exposure database. For institutional aspects, recognition procedures should be simplified, the channel for transition to medical treatment for occupational accidents should be smoothed, and the role of medical treatment for occupational accidents should be clarified to increase the utilization rate and to make healthcare costs of occupational diseases allocated in a more just manner. For occupational diseases with long latency periods and difficulties in collecting evidences of exposure, recognition criteria may be revised to allow cases with inadequate proof of evidence, and post-retirement health screenings for workers of high-risk occupations should be strengthened. There is also need to raise social awareness of occupational injuries and diseases through education.