“创新支付制度，提高卫生效益”项目的实施对参合农民门诊、住院卫生服务利用的影响研究

发布时间：2018-04-07 15:47

本文选题：“创新支付制度　切入点：提高卫生效益”　出处：《宁夏医科大学》2013年硕士论文

【摘要】：目的结合宁夏“创新支付制度，提高卫生效益”医改项目的实施，了解项目实施前后试点县与对照县参合农民卫生服务利用及影响因素、病人就诊流向、医疗费用的变化，以评价项目实施的效果，为我区新农合可持续发展和促进农民就医行为的改变、提高农民健康水平提供数据支持，为医疗卫生体制改革总目标提供可借鉴的政策依据。方法2009年基线调查采用二阶段分层随机抽样的方法，对试点县（盐池县、海原县）和对照县（同心、西吉、彭阳县）的农村居民进行入户调查，2011、2012年进行追踪调查。对试点县和对照县三年门诊、住院卫生服务需要及利用的指标、病人流向、医疗费用的变化趋势进行单因素分析，采用多因素Logistic回归模型分析试点县和对照县农民门诊和住院卫生服务利用的主要影响因素。结果（1）以2009年对照县调查人口为标准人口进行标准化后，三年试点县与对照县的标准化两周患病率之间的差异均有统计学意义，试点县高于对照县,试点县由基线调查的21.0%降至17.3%；三年试点县与对照县的标准化慢性病患病率之间的差异也有显著性，试点县高于对照县；自感病轻和经济困难是两周患病未治疗的主要原因，与2009年的基线调查相比，试点县和对照县在随访调查中因经济困难未治疗的比例均有所下降。（2）三年试点县与对照县的标准化两周就诊率之间的差异均有统计学意义，且试点县高于对照县，试点县基线调查的两周就诊率较随访调查高。年份、性别、民族、年龄、婚姻状况、文化程度、有无慢病均是影响试点县和对照县农村居民门诊卫生服务利用的因素。（3）门诊机构就诊病人流向发生改变，基线调查时，两周患病就诊机构以县级医院和乡镇卫生院为主，追踪调查中，两周患病就诊机构则主要是以村卫生室和乡镇卫生院为主；（4）三年试点县与对照县的标准化住院率之间的差异均有统计学意义，试点县较对照县高，试点县2012年标准化住院率高于基线调查。应住院而未住院的原因以经济困难为主，相对基线调查，因经济困难而未住院的比例有所减少；年份、性别、民族、年龄、婚姻状况、文化程度、有无慢病是影响农村居民三年住院卫生服务利用的因素；（5）基线调查县级医院是被调查居民住院选择的主要机构，在2011和2012年的追踪调查中，去县级医院和县级以上医院住院的比例均有增加，而乡镇卫生院和其他医疗机构的住院比例由所下降，住院病人的流向仍有不合理；（6）与2009年比较，2010年和2011年乡镇卫生院和县级医院的年门诊次均费用呈上升趋势，而乡镇卫生院的实际补偿比例上升趋势较明显，，县级医院的补偿比例稍有下降；各级医疗机构的年住院次均费用均呈上涨趋势，在补偿比例方面，乡镇卫生院和县内县级医院都有增加，尤其是乡镇卫生院，而县外医院的住院补偿比例呈下降趋势。结论自“创新支付制度，提高卫生效益”医改项目的实施后，试点县农村居民卫生服务需求与利用发生了变化，新农合参合率逐年上升；试点县农村居民的门诊卫生服务需要及利用高于对照县，因经济困难未治疗的比例也有所下降，新农合报销比例的增加在一定程度上减轻了农村居民因看病而产生的经济负担；门诊就诊机构由乡镇卫生院、县级医院向村卫生室转变，使农民可以充分利用医疗资源，能够就近就医，而住院病人的就诊流向仍以县级医院为主，基层医院还是不能被充分利用；农民看病负担仍然较高，人均次均费用仍然呈上升趋势；建议加强县、乡、村医疗机构服务体系和三级网络建设，并加强对医疗机构的监督，建立严密的服务过程和结果监控体系，提高医务人员的服务能力和水平，引导居民加大对乡村两级卫生服务的利用，降低医疗费用。
[Abstract]:The purpose of this paper is to improve the implementation of health care reform project of Ningxia ' s innovative payment system and improve the health benefits , and to understand the changes of health service utilization and influencing factors , the patient ' s medical expenses and medical expenses before and after the implementation of the project , so as to evaluate the effect of the project implementation , to provide data support for the sustainable development of the new agriculture and agriculture in my district and to promote the farmers ' medical behavior , and to provide the policy basis for reference for the overall goal of the reform of the health care system .

Methods A two - stage stratified random sampling method was adopted in the baseline survey in 2009 . In 2011 and 2012 , the investigation was carried out for the rural residents in the pilot counties ( Yanchi County , Haiyuan County ) and the control county ( concentric , Xiji , Pengyang County ) . The factors influencing the utilization of outpatient and inpatient health services in trial and control counties were analyzed by a multi - factor logistic regression model .

Results ( 1 ) After the standardized population was standardized in the control county in 2009 , the difference between standardized two - week prevalence rate in three - year trial - point county and control county was statistically significant , and the trial - point county was higher than that in the control county , and the trial - point county decreased from 21 . 0 % of baseline survey to 17.3 % ;
There was also a significant difference between the standardized chronic disease prevalence rates in trial and control counties in three years , compared with the control counties in the county ;
Compared with the baseline survey in 2009 , the two - week visit rate between trial and control counties was higher than the follow - up survey . ( 2 ) The two - week visit rate between trial point county and control county was higher than that in control county .
( 4 ) There was a significant difference between standardized hospitalization rates between trial and control counties in three years , and the standardized hospitalization rate was higher in trial - point county than in the control county , and the standardized hospitalization rate was higher in trial - point county than that in the baseline survey . The reasons for hospitalization were mainly economic difficulties , and the relative baseline survey showed that the proportion of non - hospitalization was reduced due to economic difficulties ;
Year , sex , nationality , age , marital status , the degree of culture and the presence or absence of chronic disease are the factors that affect the utilization of health services for rural residents in three years ;
( 5 ) Baseline survey county level hospitals are the main institutions to be selected by residents in hospitals . In the follow - up survey in 2011 and 2012 , the proportion of hospitalization among county hospitals and hospitals above the county level has been increased , while the proportion of hospitalization in township hospitals and other medical institutions is reduced , and the flow direction of the residents is still unreasonable ;
( 6 ) Compared with 2009 , the annual outpatient costs of township hospitals and county hospitals increased in 2010 and 2011 , while the proportion of actual compensation in township hospitals increased obviously , and the compensation ratio of county hospitals decreased slightly ;
The annual hospitalization expenses of medical institutions at all levels are rising , and in the proportion of compensation , there is an increase in the county level hospitals in township hospitals and counties , especially in township hospitals , while the proportion of hospitalization compensation in hospitals outside the county is declining .

Conclusion Since the implementation of the " innovation payment system and the improvement of health benefits " , the demand and utilization of health services of rural residents in trial counties have changed .
The demand and utilization of outpatient health services for rural residents in trial counties is higher than that in the control counties , and the proportion of the new non - treatment of the economic difficulties has declined , and the increase of the proportion of the new non - farming combined reimbursement has reduced the economic burden of the rural residents due to the disease ;
The outpatient medical institution is changed from the township hospital and county hospital to the village clinics , so that the farmers can take full advantage of medical resources , so that the medical resources can be fully utilized , and the flow direction of the inpatients is still mainly at the county level hospital , and the primary hospitals can not be fully utilized ;
The burden of farmer ' s disease is still high , and the average cost per capita is still rising ;
It is suggested to strengthen the service system of county , township and village medical institutions and the construction of tertiary network , strengthen the supervision of medical institutions , establish strict service process and result monitoring system , improve the service ability and level of medical personnel , guide the residents to increase the use of health services at the rural two levels , and reduce medical expenses .

【学位授予单位】：宁夏医科大学
【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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