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Rehabilitation Practice and Science

Translated Title

醫療機構服務品質評估系統研究：以類神經網路預測復健科健保申報之核減率為例

Abstract

The goal of this study was to investigate the subtle interrelationships between the insurance claim’s data and clinic performance of medical institutes. Because the medical claims data increase drastically, the review efforts and processes become rather complex and inefficient. The physicians of review committee should have an enterprise view of the claims.We create the performance indicators from consistent data & meta data established from the clinic performance of medical institutes. We adopted 16 outpatient review indicators. We collected rehabilitation claims in middle branch of NHIB since July 1996 till Feb 1997. The prediction model created using both the neural network and statistical methods. All the medical institutes are divided into three groups. Group A reclaimed rate ranges from 0 to 3.5%. Group B reclaimed rate is from 3.5% to 7%. Group C reclaimed rate is above 7%. We used the review indicators as learning inputs & the categories of reviewed claims rate as learning outputs. The neural network system was fed with these data & enforced to discern the mapping from inputs to the proposed output. The results of group prediction accuracy rate showed that the Neural Networks outperformed the statistical model. The group prediction accuracy rate was 92.31% for local clinic that consisting of only one physician, while 74.07% of accuracy rate for regional hospitals whose individual reclaimed rate were collected from several departments or physicians. The results showed that the prediction accuracy rate of clinics groups was better than that of the hospital groups. This study applied neural network whose learning architecture was constructed using the genetic algorism to provide physicians the ability to access data and turn it into valuable information. This information can help physician of review committee to evaluate the performance of medical institutes. If we can produce a set of review indicators from the database of medical claims database, the combination of data warehouse and review indicators will deliver appropriate and cost-effective solutions in the review strategy.

Language

Traditional Chinese

First Page

185

Last Page

193

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