华东某地新型农村合作医疗住院补偿方案评价与调整

发布时间：2018-03-04 00:29

本文选题：新型农村合作医疗　切入点：补偿方案　出处：《复旦大学》2013年硕士论文　论文类型：学位论文

【摘要】：一、研究目的与意义新型农村合作医疗制度(以下简称“新农合”)的目标是在保障收支平衡的基础上,形成农村居民医疗经济风险合理共担机制,最大程度地缓解因病致贫。本文研究对象华东某地(以下简称“A地”),从2003年开始推行该制度,在一定程度上减轻了农民疾病经济负担。但是,2008年对该地区实施的意向调查结果显示：56.4%的人认为当地因病致贫情况仍很严重,农村因病致贫占贫困户的比例大致为29.1%。近几年,当地政府不断提高新农合的筹资水平,调整住院补偿方案。但调整后的方案能多大程度解决风险?“因病致贫”缓解程度如何?能否实现“收支平衡”?若要回答这些问题,需要客观、科学评价A地新农合目标的实现程度。 2009年开始,为了应对医疗费用过快增长阻碍新农合制度可持续发展的问题,新医改要求各地积极探索新农合支付方式改革。2012年4月,卫生部、国家发展改革委、财政部三部委下发了《关于推进新型农村合作医疗支付方式改革工作的指导意见》(卫农卫发(2012)28号)；A地所在省也在2010年制定的新农合支付方式改革试点方案中提出“力争在2-3年内,在全省90%以上的统筹地区开展新农合支付方式改革”的要求。在这样的政策环境下,A地需要在客观、科学评价新农合目标实现程度的基础上,结合支付方式改革的政策要求,对新农合住院补偿方案进行调整。这也是本研究的目的所在。二、材料与方法本研究数据来是A地新农合实施的相关数据资料,包括：2007-2012年参合、筹资等基本统计资料；2010-2012年政策文件、社会经济状况等基本资料；2010-2011年门诊补偿数据库；2010年到2012年前三季度住院补偿数据库；2011年患者住院明细数据库等。主要运用了以下方法： 1、研究以政策科学理论中的简单“前-后”对比分析法为指导,通过比较新农合补偿前后各评价指标的变化情况来评价新农合制度的目标实现程度。 2、选用规范差距分析法,将A地新农合目标的实际实现程度与新农合“收支平衡、风险共担、消除因病致贫”的理想目标进行比较,明确该地新农合补偿方案的不足之处。 3、通过系统查阅新农合制度评价以及按床日付费制度相关的资料,明确本研究新农合实施效果评价指标和按床日支付标准的测算方法。 4、运用聚类分析、方差分析以及回归分析等统计方法辅助测算按床日支付标准。三、研究结果 (一)A地新农合运行效果评价 1、一般运行情况 A地新农合参合率达到100%,人均筹资水平由2007年的110元提高到2012年的400元,年均增长29.46%,高于全国人均筹资水平增长率(22.01%)。2011年A地新农合住院受益率为8.52%,住院实际补偿比为46.16%；补偿比例随着医疗机构级别的增高而依次降低。此外,2010-2012年间,A地住院总费用以年均8.38%的速度增长；2011年次均费用低于2010年,但2012年却又大幅上升并超过2010年的水平。 2、2011年A地新农合目标实现程度 2.1基金基本达到收支平衡 A地新农合资金结余率为-1.44%,基本处于相对平衡的范围内。 2.2一定程度上降低了就医经济风险,但未重点关注高风险人群人群就医经济风险相对危险度(RR)由11.84降至6.66,降幅为43.75%。其中,住院人群的RR下降幅度为46.16%。但是,补偿前RR最大值为207.86,补偿后RR最大值仍达113.40；住院费用超过最大支付能力线的人群RR下降幅度并未高于其他低费用水平人群。这提示A地的补偿方案没有重点关注高风险人群。 2.3一定程度上缓解了因病致贫,但仍不理想 A地新农合补偿前农村居民的因病致贫率为0.83%,补偿后为0.35%,下降了58.07%；补偿前因病致贫总缺口为6,083.37万元,补偿后为1,578.99万元,下降了74.04%,可见A地在一定程度上缓解了因病致贫,但距离消除因病致贫的目标还有较大差距。 (二)A地按床日支付标准按床日付费制度实施的关键是支付标准的制定。考虑到医疗费用跟疾病严重程度、治疗方式以及患者年龄等因素密切相关,本研究将患者分为重症病人、手术病人、儿科病人以及普通病人四大类；由于患者住院后不同时期、不同护理级别的医疗费用也有明显差距,所以需要对病程进行分段,将重症病人按护理等级(包括特级、一、二、三级护理)进行分段,将手术病人按照术前、中、后进行分段,而对于儿科病人和普通病人则按天数进行分段；此外,不同级别的医疗机构医疗费用差异较大,将医疗机构分为乡镇级、区级、市级三个级别,得出A地2011年各级别医疗机构各类型病人各疾病分段的实际日均费用。在此基础上,综合考虑不合理医疗费用比例、医疗产品价格指数,测算出了2013年A地的日均费用标准。为了尽量减小政策调整带来的震荡,本研究参照A地原先的补偿比例,测算出了2013年A地的按床日支付标准。最后,进一步针对按床日付费制的缺陷,提出了A地新农合管理机构对医疗机构进行监督考核的相关策略建议。 (三)A地二次补偿方案考虑到按床日支付仅针对每次的医疗费用进行补偿,未能关注全年累计自付医疗费用给农村居民造成的经济负担,因此,本研究在此基础上,为A地研制了二次补偿方案。研究首先测量按床日支付标准补偿后农民就医经济风险分布和因病致贫状况,明确了消除因病致贫风险所需的筹资额,判断出A地用于二次补偿的基金可以达到消除因病致贫的目标；其次,考虑到二次补偿方案重点关注高风险人群,确定其风险保障性质为风险型。为控制不合理的需求增长,二次补偿方案考虑共付制,即包含起付线、封顶线以及补偿比等关键要素。由于消除因病致贫是二次补偿方案的首要目标,理论上超过最大支付能力的医疗费用都应采用最高比例报销,但为了避免收入对医疗消费的直接效应给新农合制度所带来的负面影响,最终采用了多段递减式补偿的模式。 (四)A地调整后住院补偿方案的预评价本研究将二次补偿方案与按床日支付方案结合,最终形成A地2013年定点医疗机构住院补偿方案,并对其新农合目标实现程度进行了预评价,结果为：新农合基金将结余-0.29%；人群平均就医经济风险RR将下降53.10%,补偿前RR最大值为228.83,补偿后RR最大值将降为63.95,且最大支付能力以上费用水平RR降低幅度将明显高于其他费用水平,最高预计达72.05%；因病致贫率将下降87.50%,因病致贫总缺口将减小97.97%,基本消除因病致贫。四、研究创新 1、本研究从理论和实践应用的角度展示了新农合补偿方案评价和调整的全过程,针对现阶段新农合存在关键难题给予明确的解答,具有一定的指导价值。 2、本研究探索了将控制医疗费用过快增长和针对性实现新农合制度目标综合考虑来调整新农合住院补偿方案的理念,以确保新农合支付方式改革稳定进行的同时实现制度的长远目标。
[Abstract]:First, the purpose and significance of the study
The new rural cooperative medical system (NCMS) goal is to guarantee the balance of payments based on the formation of medical economic risk of rural residents reasonable sharing mechanism, greatly alleviating the poverty due to illness. This thesis focuses on a region of East China (hereinafter referred to as "A"), from the beginning of 2003 the implementation of the system, to a certain degree to alleviate the financial burden of the disease. However, on 2008 the implementation of the survey area shows that 56.4% of people think that the local poverty situation is still very serious, rural poverty accounted for the proportion of poor households is approximately 29.1%. in recent years, the local government to improve the level of financing of NCMS, adjust the hospitalization compensation. But the adjustment the scheme can greatly solve the risk? "Pccd" relief degree? How to achieve "balance"? To answer these questions, you need an objective, scientific Evaluate the realization degree of the new CMS target in A.
The beginning of 2009, in order to cope with the excessive growth of medical costs hinder the sustainable development of new rural cooperative medical system, the new health care reform urged all localities to actively explore NCMS payment reform in.2012 in April, the Ministry of health, the national development and Reform Commission, the Ministry of Finance issued three ministries "on the promotion of new rural cooperative medical payment reform work guidance (> Weinong Wei (2012) No. 28); A is also formulated in 2010 NCMS payment reform program proposed" strive to 2-3 years to carry out the requirements of the NCMS payment reform "of the whole region in the province more than 90%.
In such a policy environment, A needs to objectively and scientifically evaluate the realization degree of NRCMS. Combined with the policy requirements of the payment reform, we should adjust the inpatient reimbursement program of the new rural cooperative medical system, which is also the purpose of this research.
Two, materials and methods
The data of this study is to the related data, the A implementation of the system include: 2007-2012 years of participation, the basic statistical data of financing; 2010-2012 years of policy documents, social and economic conditions and other basic information; 2010-2011 years of outpatient compensation database; 2010 to 2012 before the three quarter of 2011 in hospital compensation database; patients in detail database.
The main use of the following methods:
1, guided by the simple "front to back" comparative analysis method in policy science theory, we evaluated the target realization degree of the new rural cooperative medical system through comparing the changes of the evaluation indicators before and after the compensation of the new rural cooperative medical system.
2, the analysis specification gap, the actual A system the degree of realizing the goal of new rural cooperative medical system and the balance of payments, risk sharing, compare the ideal goal of eliminating poverty due to illness, clear the compensation project deficiencies.
3, through the systematic review of the new rural cooperative medical system evaluation and the data related to the daily payment system, we can make clear the evaluation index of the new rural cooperative medical system implementation and the calculation method of the payment standard according to the bed day.
4, using statistical methods such as cluster analysis, variance analysis and regression analysis to calculate the standard of payment according to the bed day.
Three, the results of the study
(1) evaluation of the operation effect of A
1, general operation
A NCMS participation rate reached 100%, the per capita funding level increased from 110 yuan in 2007 to 400 yuan in 2012, an average annual growth rate of 29.46%, higher than the national growth rate of per capita funding level (22.01%).2011 A NCMS hospitalization rate was 8.52%, in the actual compensation ratio is 46.16%; the compensation ratio increased with the level of medical institutions which in turn reduces. In addition, 2010-2012 years, A to the total hospitalization expenses of the average annual growth rate of 8.38% in 2011; the average expense is lower than in 2010, but in 2012 it rose sharply and exceeded the level in 2010.
The realization degree of the target of new agricultural cooperation in the past 22011 years in A
2.1 funds basically achieve balance of payments
The fund surplus rate of nncms in A is -1.44%, which is basically in the range of relative balance.
2.2 to a certain extent, the economic risk of medical treatment has been reduced, but the high risk population is not focused on.
The crowd medical risks relative risk (RR) from 11.84 to 6.66, a decline of 43.75%. among the hospitalized population decreased by RR 46.16%. but before compensation RR maximum value is 207.86, the maximum compensation after RR still amounted to 113.40; hospitalization expenses exceeds the maximum capacity to pay line group RR decline was not higher than that of other low the cost level of population. It suggests that the A compensation scheme to not focus on high risk population.
2.3 to some extent alleviate poverty due to illness, but still not ideal
A compensation before the rural residents of the poverty rate is 0.83%, after compensation for 0.35%, a decrease of 58.07%; the total compensation before the poverty gap was 60 million 833 thousand and 700 yuan, compensation for 15 million 789 thousand and 900 yuan, down 74.04%, visible A to some extent alleviate poverty due to illness, but there is a large gap between the distance to eliminate poverty the target.
(two) A according to the bed day payment standard
The per diem payment key implementation of the system is to develop payment standards. Considering the medical expenses with the severity of the disease, treatment and patient age and other factors are closely related, in this study, patients were divided into patients, surgery, pediatric patients and normal patients in four categories; due to different periods of hospitalization after different nursing level the medical expenses have significant difference, so the need for a course are segmented according to nursing patients with severe symptoms (including grade A, grade two, grade three, nursing) segments will patients according to preoperative, and after segmentation for pediatric patients and normal patients according to the number of days in the section; medical expenses between medical organizations of different levels in large medical institutions should be divided into the township level, district level, municipal level three, the patients with various types of medical institutions A 2011 all levels of segmented real disease The average daily cost.
On this basis, considering the unreasonable proportion of medical expenditure, medical products price index, calculated the average daily cost of a standard A in 2013. In order to minimize the shock of policy adjustment, the proportion of compensation to A research according to the original estimate, 2013 A per diem payment standard. Finally, for further per diem system defects, put forward the A management mechanism of supervision and appraisal suggestions on the strategies of medical institutions.
(three) the two compensation scheme for A
In consideration of the payment according to the bed, only to compensate for each medical expenses, failed to pay attention to the annual total pay medical expenses for rural residents caused by the economic burden, therefore, on this basis, A developed two times compensation scheme. Firstly, measurement payment standard compensation according to the bed, after farmers seeking economic risk distribution and the poverty situation, clear the amount of funding poverty elimination risk required, judging from A for two times the compensation fund can eliminate poverty targets; secondly, taking into account the two compensation schemes focus on high risk population, determine the nature of risk protection as the risk.
In order to control the growth of the unreasonable demand, two times the compensation scheme considering the co payment system, which includes the pay line, cap line and the compensation ratio of key elements. Due to the elimination of poverty is the primary goal of two times compensation scheme, theoretically exceeds the maximum capacity to pay medical expenses should be used on the highest proportion of reimbursement, but in order to avoid the negative impact of the direct effect of income on medical consumption brought by the new rural cooperative medical system, the multi regressive compensation model.
(four) pre evaluation of compensation scheme for hospitalized patients after A adjustment
This study will be two times the compensation scheme and the per diem payment scheme with A was formed in 2013 designated medical institutions hospitalization reimbursement scheme, and the new goal attainment in the pre evaluation, results are as follows: the new rural cooperative fund balances will be -0.29%; the average hospitalization economic risk RR population will decline by 53.10%, before the maximum compensation RR 228.83, after the compensation of the maximum value of RR will be reduced to 63.95, and above the maximum capacity to pay expenses rate will decrease the level of RR was significantly higher than that in other expenses, the highest is expected to reach 72.05%; poverty rate will decline by 87.50%, the total poverty gap will be reduced to 97.97% and eliminate poverty.
Four, research innovation
1, this research shows the whole process of evaluation and adjustment of the new rural cooperative medical compensation scheme from the perspective of theory and practice. It has certain guiding value for solving the key problems in the new rural cooperative medical system at the present stage.
2, this study explored the idea of adjusting the reimbursement program of NRCMS with the aim of controlling the excessive growth of medical costs and implementing the target of NRCMS, so as to ensure the stable reform of the NCMS payment mode and achieve the long-term goal of the system.

【学位授予单位】：复旦大学
【学位级别】：硕士
【学位授予年份】：2013
【分类号】：R197.1;F842.684;F323.89

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