医疗保险总额预付效应理论与实证研究

发布时间：2018-05-05 21:36

本文选题：医疗保险 + 支付制度　；参考：《复旦大学》2014年硕士论文

【摘要】：[背景]随着中国社会经济发展,中国医疗卫生保健事业已取得巨大发展,过去缺医少药的情况已基本改善,社会医疗保险覆盖率和保障水平也不断提升。但是卫生费用快速增长的问题却日益凸显。2009年～2011年我国卫生总费用增长率分别为20.7%,13.9%和21.5%,而2009年～2011年GDP增长率[4-61分别为9.2%,10.4%,9.2%,：卫生费用三年平均增长率高出GDP三年平均增长率9.1%,卫生费用增长速度已呈现高于经济增长速度的趋势,有效控制卫生费用已成为我国卫生领域亟待解决的重要议题。科学合理的支付方式选择是控制卫生费用、实现卫生资源有效利用的关键。而以定额、预付为特征的总额预付支付制度已被国内外诸多研究视作控制卫生费用不合理增长的有效方式之一[8-10]。总额预付制度通过控制卫生服务价格和卫生服务供给量来实现控制卫生服务总支出的目的。2009年以来政府发布的医改文件显示支付制度改革特别是总额预付改革试点是我国深化医药卫生体制改革的重要内容,因此探索研究总额预付效应是必要且急迫的。国外现阶段对总额预付的研究多关注医保支付制度本身,例如医保总额预付的支付形式、支付内容及测算方法等；关注总额预付政策实施后的最终效果,例如医疗服务费用、质量、效率、可及性及公平性等多方面变化情况,这些研究大多是根据支付方式制定者的政策目标来予以考察。而国内现阶段对总额预付的研究多关注实施医保总额预付的积极作用、存在的问题以及总额预付的影响评价,且多为案例研究。因此对总额预付效应的抽象性理论研究十分重要。[目的]在定性理论研究、数学模型构建、以及对医疗机构、医生、患者的实证研究基础上,系统探讨医疗保险总额预付效应,提出相应的政策建议,为相关管理和决策提供科学参考。理论研究。基于定性理论研究内容和数学模型构建内容,应用拉格朗日函数求解医院在总额预付限制下最优效用函数,解释求解所得定量最优解含义,探讨医疗保险总额预付效应,提出相应的政策建议,为相关管理和决策提供科学参考。实证研究。基于现场调查数据,对医疗机构管理者进行关键知情人访谈、对临床医生和患者进行问卷调查,考察总额预付对医院管理者、临床医生、患者行为的影响,调查管理者在总额预付下策略选取、医生对总额预付评价、总额预付实施后医院经济运行情况；调查医生在总额预付下行为策略、医生对总额预付的评价；患者在实施总额预付医疗机构就诊感受。探讨总额预付实施对医院、医生、患者实际产生的影响,并探索其可能原因,提出相应政策建议,为相关管理和决策提供科学参考。[方法]理论研究。本研究采用文献评阅方法分析总额预付的作用机制及影响,在定性理论研究基础上构建数学模型探索效应作用方向。数学模型构建基本方法包括效用函数设计和极值求解。数学模型构建完成后,对单体医院效用函数基础模型、单体医院效用函数扩展模型、医疗联合体效用函数基础模型、医疗联合体效用函数扩展模型进行极值求解。实证研究。以上海市十家试点实施医疗保险总额预付的三级医院为研究对象,调查23名医院管理者(院长、副院长、门诊办公室主任)、400名临床医生、399名住院患者(住院天数7天以上)和400名门诊患者。调查三级医院应对总额预付的管理行为和临床行为；调查三级医院实施总额预付前后医院的经济运行状况；调查实施总额预付后患者的就诊感受；调查临床医生和患者对总额预付的评价。对医疗机构管理者进行关键知情人访谈、对临床医生和患者进行问卷调查,考察总额预付对医院管理者、临床医生、患者行为的影响。对管理者调查内容主要包括总额预付下医院策略、对总额预付的评价、医院经济运行数剧等；对医生调查内容主要包括总额预付下行为策略、对总额预付的评价；对患者调查内容主要包括患者在实施总额预付试点的医院就诊感受。本研究的另一项实证调查数据来源于通过关键知情人访谈和问卷调查,结合定量与定性分析,考察全国7个省市10家三级医院实施房颤射频消融相关医保管理措施情况,重点关注医院是否实施总额预付,总额在医院与科室问分配方式,具体执行措施及监管行为。现场调查完毕后对质量合格的问卷采用Epidata软件进行数据录入,数据录入后将数据库导出到E xcel软件中进行基本数据分析。其后采用stata100软件对调查结果进行描述性统计分析,并对调查对象的基线变量进行影响因素分析,从而剔除偏倚因素,采用SAS软件对调查结果进行多因素分析。[结果]实施总额预付后,单体医院仅向医保患者提供服务时,当实现单体医院总体效用最大化时,服务质量无法达到最优服务质量；单体医院同时向医保患者和自费患者提供服务时,当实现单体医院总体效用最大化时,服务质量不确定性增加；医疗联合体内部各医院仅向医保患者提供服务时,当实现医疗联合体总体效用最大化时,服务质量无法达到最优服务质量；医疗联合体内部各医院同时向医保患者和自费患者提供服务时,当实现医疗联合体总体效用最大化时,服务质量不确定性增加。[结论与建议]理论研究与实证研究均表明总额预付制度会对医保患者接受的服务质量产生影响；理论研究与实证研究均表明总额预付会导致推诿医保病人、医疗不足、将机构内部资源分配偏向自费诊疗、自费药品及自费患者,从而影响医保患者或总额预付覆盖人群对医疗服务的可及性及其服务质量。建议需要多种精细化配套政策支持总额预付,进一步纳入临床路径作为总额预付质量监控机制的组成部分,进一步探索联合体总额预付管理。
[Abstract]:[background] with the development of China's social and economic development, China has made great progress in medical and health care. In the past, the situation of lack of medicine has been basically improved, the coverage rate of social medical insurance and the level of security are also increasing. However, the problem of the rapid growth of health costs has increasingly highlighted the growth rate of total health expenses in China from.2009 to 2011. Not 20.7%, 13.9% and 21.5%, while the GDP growth rate of [4-61 from 2009 to 2011 is 9.2%, 10.4%, 9.2% respectively. The average growth rate of the health cost three years is higher than the average growth rate of GDP three years, and the growth rate of health costs has been higher than the economic growth rate. The effective control of the health expenditure has become an important problem to be solved in our health field. Issue. Scientific and reasonable choice of payment method is the key to control health costs and achieve effective use of health resources. A quota, prepaid payment system has been considered as one of the effective ways to control irrational growth of health costs at home and abroad. The [8-10]. total prepayment system is controlled by the price of health service. And the supply of health services to achieve the goal of controlling the total expenditure of health services in.2009 years since the government has issued medical reform documents show that the reform of the payment system, especially the total pre payment reform, is an important part of the deepening of the reform of the medical and health system in China. Therefore, it is necessary and urgent to explore the prepaid effect of the total amount. The study of total pre payment pays much attention to the medical insurance payment system itself, such as the form of payment in advance of the total medical insurance, the content of payment and the method of calculation, and so on; the final effect after the implementation of the total prepaid policy, such as medical service costs, quality, efficiency, accessibility and fairness, is mostly based on the payment party. At the present stage, the research on total pre payment in China pays much attention to the positive role of the pre payment of total medical insurance, the existing problems and the impact assessment of the total prepayment, and most of them are case studies. Therefore, it is very important for the abstract theory to study the total prepaid effect. On the basis of the empirical study of the medical institutions, doctors and patients, this paper systematically discusses the prepaid effect of the total medical insurance and puts forward the corresponding policy suggestions to provide scientific reference for the related management and decision-making. Theoretical research is based on the content of qualitative theory and the construction of the mathematical model and the Lagrange function is applied to solve the medical treatment. Under the total prepaid limit, the hospital has the optimal utility function, explains the meaning of the optimal solution, discusses the prepayment effect of the total medical insurance, and puts forward the corresponding policy suggestions to provide scientific reference for the related management and decision. A questionnaire survey was conducted with the patients to investigate the effects of total prepayment on hospital managers, clinicians, and patients' behavior, to investigate the total prepaid strategy selection of the managers, the total pre payment evaluation of the doctors, the economic operation of the hospital after the total advance payment, the total prepaid behavior strategy of the doctors, and the evaluation of the total prepayment by the doctors; Patients in the implementation of the total prepaid medical service experience. Explore the impact of total advance payment on hospitals, doctors, patients, and explore the possible reasons, put forward relevant policy recommendations, provide scientific reference for related management and decision-making. [method] theoretical research. This study uses literature review to analyze the total amount prepaid machine. On the basis of qualitative theory, a mathematical model is constructed to explore the direction of effect. The basic methods of constructing the mathematical model include the utility function design and the extreme value solution. After the completion of the mathematical model, the basic model of the utility function of the single hospital, the expansion model of the utility function of the single hospital and the basic model of the utility function of the medical consortium are established. An empirical study was conducted on the three level hospital of ten pilot medical insurance prepaid in Shanghai. 23 hospital managers (Dean, vice president, outpatient office director), 400 clinical doctors, 399 hospitalized patients (hospitalized days 7 days or more) and 400 were investigated. Outpatient patients. Investigate the management behavior and clinical behavior of the total amount prepaid by the three level hospitals; investigate the economic operation of the hospital before and after the total pre payment of the three level hospitals; investigate the experience of the patients after the total payment of the total prepayment; investigate the prepaid evaluation of the clinicians and patients. A questionnaire survey of clinicians and patients was conducted to investigate the impact of total prepayment on hospital managers, clinicians, and patient behavior. The main contents of the survey included the total prepaid hospital strategy, the total prepayment evaluation, the hospital economic operation, and so on. The contents of the doctor's investigation included the total prepaid behavior. The content of the survey was mainly included in the patient's experience in the implementation of the total prepaid trial. Another empirical data from this study was based on the interview and questionnaire survey of key lovers, combined with quantitative and qualitative analysis, and examined 10 three level hospitals in 7 provinces and cities to carry out RFID radiofrequency. The relevant medical insurance management measures are ablated, focusing on whether the hospital is carrying out the total prepayment, the total amount in the hospital and the Department, the specific implementation measures and supervision behavior. After the field investigation, the quality qualified questionnaire is used for data entry by Epidata software, and the database is exported to the E Xcel software after the data entry. After the analysis of the data, the stata100 software was used to analyze the survey results with descriptive statistics, and to analyze the influencing factors of the baseline variables of the subjects, so as to eliminate the bias factors and to use the SAS software to analyze the results of the survey. [results] after the total payment was prepaid, the single hospital provided service to the medical insurance patients only when the total amount of the total payment was prepaid. When the overall utility of a single hospital is maximized, the quality of service can not reach the best quality of service; when the single hospital provides the service to the medical insurance patients and the self paid patients at the same time, when the overall utility of the single hospital is realized maximization, the uncertainty of the service quality is increased; when the hospitals of the medical union body are only providing services to the medical insurance patients, When the overall utility of the Medical Federation is maximized, the quality of service can not reach the optimal quality of service; when the hospitals within the Medical Union provide services to the medical insurance patients and the self-paid patients at the same time, the uncertainty of the quality of service is added when the overall utility of the Medical Federation is maximized. [Conclusion and suggestion] theory research and empirical study Both the theoretical and empirical studies show that the total prepayment will lead to the prevarication of medical insurance patients and medical inadequacy, and the allocation of internal resources is biased towards the self cost diagnosis and treatment, the self-fee medicine and the self paid patients, which affect the medical insurance patients or the total prepaid coverage of the total population. The availability and quality of medical services and its quality of service. It is suggested that a variety of fine matching policies should be required to support total prepayment, and further integrated into the clinical path as part of the total prepaid quality monitoring mechanism, and further explore the prepaid management of the total volume of the United States.

【学位授予单位】：复旦大学
【学位级别】：硕士
【学位授予年份】：2014
【分类号】：R197.1;F842.684

【参考文献】