乙型肝炎患者直接医疗费用及医疗保险门诊政策研究

发布时间：2018-02-01 17:40

本文关键词： 乙型肝炎直接医疗费用医疗保险门诊政策　出处：《东南大学》2017年硕士论文　论文类型：学位论文

【摘要】：目的分析乙肝患者的直接医疗费用及其构成、影响因素,探讨乙肝患者医疗保险门诊政策的实施现状及存在的主要问题,提出减轻乙肝患者经济负担的合理措施,为完善医疗保险政策提供依据。方法通过图书馆、互联网、政府平台等搜集江苏省部分地区医保门诊政策的相关文件和管理办法,并进行归纳和整理。描述江苏省13个统筹地区职工医保、居民医保和新农合的医保门诊政策现状,包括医保门诊病种设置、乙肝患者的保障情况以及政策的具体实施情况(待遇水平、支付方式等)。对江苏省2所三级医院感染科的乙肝就诊患者50人和3所三级医院感染科的临床医生5人进行访谈,了解乙肝患者年人均门诊就诊次数以及医生对《乙肝防治指南》的解读和应用情况。选取江苏省2所三级医院2014年1～12月14910人次门诊乙肝患者和966人次住院乙肝患者作为实证研究样本,从医院病例病案系统获取患者的直接医疗费用及就诊信息。描述门诊和住院乙肝患者的直接医疗费用及其构成、次均直接医疗费用、年门诊费用、医保报销费用和报销比例等;对乙肝患者的直接医疗费用、住院天数进行单因素分析;对住院乙肝患者直接医疗费用进行多元线性回归分析。结果1.乙肝患者直接医疗费用(1)门诊乙肝患者在14910人次门诊乙肝病例中,男性8952人次(60.04%),女性5958人次(39.96%);25～34岁年龄组就诊人次最多(4131人次),占27.71%,0～14岁年龄组最少(56人次),占0.38%;医保患者9940人次(66.67%),缴费患者4970人次(33.33%);在医保患者中,职工医保患者9830人次(98.89%),居民医保患者110人次(1.11%);患者抗病毒治疗率为37.46%,职工医保患者抗病毒治疗率(37.80%)高于居民医保患者(29.09%)。14910人次门诊乙肝病例直接医疗费用总额为14188409.81元。次均门诊费用为951.60元,其中药品费比重最高(790.27元),占83.05%;年人均门诊就诊次数为12次,年人均门诊费用为11419.20元;次均门诊费用男性(997.71元)高于女性(882.32元),差异有统计学意义(P0.05);30～59岁年龄组(980.33元)最高,差异有统计学意义(P0.05);职工医保患者(953.22元)高于居民医保患者(811.05元),差异有统计学意义(P0.05);抗病毒治疗患者(1094.77元)高于未抗病毒治疗患者(865.86元),差异有统计学意义(P0.05);患者次均报销比例为62.32%,职工医保患者(62.51%)高于居民医保患者(42.76%),差异有统计学意义(P0.05)。(2)住院乙肝患者在966人次住院乙肝病例中,男性649人次(67.18%),女性317人次(32.82%);25～34岁年龄组住院患者最多(339人次),占35.09%,0～14岁年龄组最少(11人次),占1.14%;医保患者554人次(57.35%),缴费患者412人次(42.65%)。在医保患者中,职工医保患者526人次(94.95%),居民医保患者28人次(5.05%);患者抗病毒治疗率为38.61%,职工医保患者抗病毒治疗率(39.35%)高于居民医保患者(32.14%);住院天数平均24.78±16.81天,最多为15～29天住院天数组(416人次),占43.06%,最少为≥60天住院天数组(51人次),占5.28%;住院天数(中位数)男性(21天)多于女性(19天),差异有统计学意义(P0.05);医保患者(24天)多于缴费患者(17天),差异有统计学意义(P0.05);职工医保患者(24天)多于居民医保患者(22.5天),差异有统计学意义(P0.05)。966人次住院乙肝病例直接医疗费用总额为12714108.85元。次均住院费用13161.60元,其中药品费比重最高(9025.09元),占68.57%;次均住院费用男性(13711.37元)高于女性(12036.05元),差异有统计学意义(P0.05);30天及以上住院天数组(18255.02元)高于其他住院天数组,不同住院天数组间费用差异有统计学意义(P0.05);医保患者(14153.12元)高于缴费患者(11828.35元),差异有统计学意义(P0.05);重度乙肝患者(17256.20元)最高,中度乙肝患者(12827.62元)次之,轻度乙肝患者(11628.48元)最低,不同疾病严重程度组间费用差异有统计学意义(P0.05);抗病毒治疗患者(13957.82元)高于未抗病毒治疗患者(12660.78元);患者次均报销比例为70.45%,职工医保患者(70.88%)高于居民医保患者(60.95%),差异有统计学意义(P0.05);多元逐步回归分析显示,住院天数、疾病严重程度、抗病毒治疗、结算方式是住院费用的影响因素(P0.05)。2.医保门诊政策现状及乙肝患者保障情况江苏省各统筹地区的医保门诊政策项目名称各不相同,主要有门诊慢性病、门诊特殊病、门诊大病等;门诊病种数量差异较大,多则几十种,少则只有几种。在13个研究地区的医保门诊政策中,职工医保有12个地区将乙肝纳入保障范围,居民医保只有5个地区纳入乙肝,新农合则有9个地区将乙肝纳入范围;各地政策规定的乙肝疾病类型也有所不同,一些地区包括所有乙肝相关疾病,有的地区只包括部分乙肝相关疾病,如肝硬化失代偿期、重型肝炎等。不同地区之间、同一地区的不同医保制度之间,医保门诊政策在就医管理、筹资方式、待遇水平、支付方式上存在较大差异,呈现"碎片化"现象。结论乙肝患者直接经济负担较重,存在医疗费用结构不合理,抗病毒治疗率较低等问题。乙肝患者的医疗保障水平有限,医保政策差异大,缺乏一定的公平性。应逐步完善医疗保障制度顶层设计,缩小各地医保政策差距,逐步将乙肝纳入门诊保障范围并提高其待遇水平;同时规范乙肝诊疗行为,加强乙肝防治工作,以减轻乙肝患者经济负担,维护其健康权益。
[Abstract]:Objective to analyze the direct medical costs of the patients with hepatitis B and its composition, influence factors, to explore the implementation status of hepatitis B patients with medical insurance outpatient policy and existing problems, put forward reasonable measures to reduce the economic burden of hepatitis B patients, provide the basis for the improvement of medical insurance policy. Through the library, Internet, government platform to collect relevant documents in some areas of Jiangsu province outpatient medical insurance policy and management methods, and summarize and organize. Describe the 13 overall planning area of Jiangsu Province, health care workers, outpatient medical insurance policy situation of residents and the new rural cooperative medical insurance, including Medicare outpatient disease specific implementation of hepatitis B patients and security policy (salary payment etc.). Department of infectious disease in Jiangsu 2 grade three hospital infection of hepatitis B patients 50 and 3 grade three hospital clinicians 5 people were interviewed about hepatitis B The average per capita annual outpatient clinic visits and doctors on hepatitis B prevention and treatment guidelines > < the interpretation and application of Jiangsu province were selected. 2 level three hospital in 2014 1~12 months 14910 people outpatient hepatitis B patients and 966 hospitalized patients with hepatitis B as the study sample, obtain patients with direct medical costs and medical information from the hospital medical records system. Describe the clinic and direct medical costs for hospitalized patients with hepatitis B and its components are direct medical costs, annual outpatient costs, Medicare reimbursement fees and reimbursement; the direct medical costs of the patients with hepatitis B, hospitalization days were analyzed by single factor analysis of hospitalized patients with hepatitis B; the direct medical cost of multivariate linear regression analysis. The results of 1. patients with hepatitis B direct medical costs (1) 14910 people in outpatient patients with hepatitis B hepatitis B outpatient cases, 8952 male passengers (60.04%), 5958 female passengers (39.96%); 25~34 years of age Group visits the most (4131 times), accounting for 27.71%, at least 0~14 year old age group (56 people), accounting for 0.38% of Medicare patients; 9940 people (66.67%), the payment of 4970 patient visits (33.33%); in Medicare patients, health care workers were 9830 people (98.89%), residents Medicare patients 110 people (1.11%); patients with antiviral treatment rate was 37.46% and the rate of health care workers in patients treated with antiviral therapy (37.80%) than the residents of Medicare patients (29.09%) total.14910 million outpatient hepatitis B cases direct medical cost was 14188409.81 yuan. The average outpatient cost is 951.60 yuan, of which the highest proportion of drug costs (790.27 yuan), accounting for 83.05%; per capita outpatient visits for 12 years second, per capita outpatient expenditure was 11419.20 yuan; the average outpatient expenses (997.71 yuan) of male was higher than female (882.32 yuan), the difference was statistically significant (P0.05); 30~59 year old age group (980.33 yuan) the highest, the difference was statistically significant (P0.05); health care workers Patients (953.22 yuan) higher than the residents of Medicare patients (811.05 yuan), the difference was statistically significant (P0.05); antiviral therapy patients (1094.77 yuan) was higher than that in patients undergoing antiviral therapy (865.86 yuan), the difference was statistically significant (P0.05); patients with average reimbursement of 62.32%, health care workers (62.51%) higher than that of patients with medical insurance patients (42.76%), the difference was statistically significant (P0.05). (2) hospitalized inpatients with hepatitis B hepatitis B cases in 966 people, male 649 people (67.18%), 317 female passengers (32.82%); 25~34 patients up to age group (339 persons), accounting for 35.09%, 0~14 year old age group (at least 11 passengers), accounting for 1.14% of Medicare patients; 554 people (57.35%), the payment of 412 patient visits (42.65%). In the patients with medical insurance, health care workers were 526 people (94.95%), residents Medicare patients 28 people (5.05%); patients with antiviral treatment rate was 38.61% and the rate of health care workers (39.35% patients treated with antiviral therapy ) than the residents of Medicare patients (32.14%); the average hospitalization time was 24.78 + 16.81 days, up to 15~29 days of hospitalization group (416 persons), accounting for 43.06%, at least for at least 60 days hospitalization group (51 people), accounting for 5.28%; hospitalization days (median) male (21 days) than women (19 days), the difference was statistically significant (P0.05); Medicare patients (24 days) than to pay patients (17 days), the difference was statistically significant (P0.05); employee medical insurance patients (24 days) than residents of Medicare patients (22.5 days), the difference was statistically significant (P0.05).966 inpatient total direct medical costs of hepatitis B cases 12714108.85 yuan. The average hospitalization cost of 13161.60 yuan, of which the highest proportion of drug costs (9025.09 yuan), accounting for 68.57%; the average hospitalization cost of male was higher than female (13711.37 yuan) ($12036.05), the difference was statistically significant (P0.05); 30 or more days of hospitalization group (18255.02 yuan) higher than other days of hospitalization no group. There was statistical significance between group differences with hospitalization costs (P0.05); Medicare patients (14153.12 yuan) higher than that of patients with fee (11828.35 yuan), the difference was statistically significant (P0.05); patients with severe hepatitis B (17256.20 yuan) the highest, moderate hepatitis B patients (12827.62 yuan) of hepatitis B patients with mild (11628.48 yuan) the lowest. There was statistical significance between the groups of different disease severity, the cost difference (P0.05); antiviral therapy patients (13957.82 yuan) was higher than that in patients undergoing antiviral therapy (12660.78 yuan); the average reimbursement rate for 70.45% patients, health care workers (70.88% patients) than the residents of Medicare patients (60.95%), the difference was statistically significant (P0.05); multiple stepwise regression analysis showed that the degree of serious illness, hospitalization, antiviral treatment, settlement is the influence factors of hospitalization expenses (P0.05).2. outpatient medical insurance policy with hepatitis B status and CO ordinating the various health situation in Jiangsu Province The outpatient policy project name is different, the main chronic disease outpatient and outpatient special disease, serious illness; outpatient disease is great difference in the number of more than dozens of little. Only a few policy in 13 areas of outpatient medical insurance, health care workers in 12 areas will be included in the scope of protection of hepatitis B, Medicare residents only the 5 regions included hepatitis B, NCMS has 9 areas will be included in the scope of hepatitis B disease; around policy types are different, some areas including all HBV related diseases, including some areas only part of hepatitis B virus related diseases, such as cirrhosis, severe hepatitis. Among different regions, between different medical insurance system for the same a region, in the medical management of outpatient medical insurance policy, financing, the level of treatment, there is a big difference between the way of payment, showing the phenomenon of "fragmentation". Conclusion the direct economic burden of hepatitis B patients than Medical costs are heavy, unreasonable structure, low rate of antiviral therapy of hepatitis B patients. The level of medical care, health insurance policy differences, lack of fairness. We should perfect the top-level design of medical security system gradually, reduce the medical insurance policies will be gradually incorporated into the gap, hepatitis B outpatient insurance range and improve its level of treatment; at the same time specification for diagnosis and treatment of hepatitis B, hepatitis B to strengthen prevention and control work, to reduce the economic burden of patients with hepatitis B, safeguard the health rights.

【学位授予单位】：东南大学
【学位级别】：硕士
【学位授予年份】：2017
【分类号】：R512.62;F842.684

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