不同基本医疗保险的老年居民卫生服务利用研究

发布时间：2018-05-19 16:20

本文选题：基本医疗保险 + 老年　；参考：《复旦大学》2014年硕士论文

【摘要】：前言面对人口老龄化及老年人卫生服务压力的挑战,浙江省杭州市具备一定的社会经济基础来应对。杭州市建立了完整的基本医疗保障制度,2011年其城镇居民基本医疗保险、新型农村合作医疗整合为城乡居民基本医疗保险,同时改变了筹资标准和提高了门诊与住院的保障待遇水平。不同基本医疗保险之间的差异、基本医疗保险政策的变化、不同医保人群自身的特征都可能对老年人的卫生服务利用产生影响,但目前缺少证据支持。目的本研究旨在通过2009～2013年杭州市家庭入户调查资料,掌握老年居民的参保情况,了解城镇职工基本医疗保险和城乡居民基本医疗保险老年人的社会人口学特征、经济状况、健康状况,分析其门诊服务利用和住院服务利用的基本情况和变化趋势并进行比较,探索当前社会环境下不同基本医疗保险老年人卫生服务利用的影响因素,为改善老年人卫生服务利用和促进老年人健康提供参考依据。方法通过文献评阅,指导不同基本医疗保险下老年人卫生服务研究。以杭州市城镇居民户籍家庭为总体进行多阶段分层随机抽样,通过家庭入户调查获得2009～2013年老年人的个人基本情况、病伤及两周就诊情况、住院情况、健康自我评价和家庭收支情况数据。所使用的调查问卷是以第四次国家卫生服务调查问卷为基础,根据研究目的改编成的杭州市家庭健康调查表。为保证数据的可比性,五次杭州家庭入户调查的方法保持了一致,并采取严格的质量控制措施。所有核实无误的家庭入户调查数据应用EpiData 3.0进行录入,然后应用SPSS 17.0和Excel 2010进行数据清洗、统计描述和统计分析。分析方法有分层分析、比较分析、多因素回归分析等；显著性检验方法有方差分析、LSD-t检验、Person卡方检验等。结果1.老年人群基本情况2009～2013年调查各回收有效问卷837份、814份、843份、861份和825份,其中老年人口数量分别为755人、800人、859人、966人和967人,各占当年样本总人口的26.4%、29.3%、31.5%、33.6%和33.6%。每年参加城镇职工医保的老年人比例基本在75%-80%之间,而参加城乡居民医保(原城镇居民医保和新农合)的老年人比例则在15%-20%之间,总合都超过95%。城镇职工医保组和城乡居民医保组的老年人社会人口学特征在五年内分别都保持了一致,但老年人的家庭经济状况随着时间发生了改变,经过消费价格指数调整,两组家庭人均收入的平均年增长率分别为8.7%和10.5%,家庭人均支出则分别为8.7%和4.3%。城镇职工医保组老年人总是比城乡居民医保老组年人更为年长、男性比例更多、在婚比例更高、受教育程度更高、家庭人均收入水平更高,但两组之间的家庭人均支出水平没有统计学显著差异。2.老年人健康状况与卫生服务需要2009～2013年城镇职工医保老年人的慢性病患病率高于城乡居民医保老年人,前者为70%～80%,后者为50%～60%,两者均都高于全国水平。调查期间不同医保组老年人患病率最高的三种慢性病病种没有变化,都是高血压、心脏病和糖尿病。老年人的两周患病率也较高,城镇职工医保老年人的患病率水平在60%以上和全国大城市老年人群水平相当,城乡居民医保老年人的患病率水平则相对略低一些。城镇职工医保组内和城乡居民医保组内,老年人的EQ-5D指数得分为0.845～0.918, EQ-VAS得分为71.1～76.7,高于全国大城市地区老年人水平。老年人的EQ-5D指数得分和EQ-VAS得分在不同医保组之间的差异均无统计学显著意义。3.老年人的门诊服务需求与利用城镇职工医保组内和城乡居民医保组内,其2009～2013年老年人的平均两周就诊率分别为57.0%和32.9%,两者之间的差异具有统计学显著意义。城镇职工医保组的两周就诊率高于全国大城市地区老年人水平,而城乡居民医保组低于该水平。高血压和糖尿病在不同医保组内都是常见的两周就诊疾病；另外,每年城镇职工医保组顺位前三的两周就诊疾病还包括心脏病,城乡居民医保组顺位前三的还包括感冒或胃肠道疾病。2009～2013年城镇职工医保老年人在社区卫生服务机构就诊的比例约占50%-65%,而城乡居民医保老年人的相应比例略高一些,约占60%～75%。老年人选择首诊机构的主要原因是距离近和方便。不同医保组内,老年人的自我医疗比例也都较高,一般在30%～40%之间。4.老年人的住院服务需求与利用城镇职工医保组内和城乡居民医保组内,2009～2013年老年人的住院率水平都在12%-20%之间,和全国水平相当。在所有老年人中,每年住院疾病顺位最高的都是心脏病,其他疾病如胃肠道疾病、脑血管疾病、糖尿病、癌症、肺病、高血压、白内障也时有进入前三位。相同基本医疗保险下不同年份,老年人的住院机构都是以在市及以上医院为主。虽然基本医疗保险对市级以上医院的统筹支付比例低于其他医疗机构,但对老年人选择住院机构的行为并无明显影响。城镇职工医保组内和城乡居民医保组内,老年人的平均住院大数和应住院而未住院比例都有所下降。5.老年人的医疗费用个人负担及家庭卫生服务支出经过消费价格指数调整后,每年城镇职工医保组在社区卫生服务机构的次均门诊医疗费用为200元以上,其中自付约40～60元,在市及以上医院的次均门诊医疗费用为400元以上,其中自付约90～130元；城乡居民医保组在社区卫生服务机构的次均门诊医疗费用为200元以下,其中自付约40～80元。不同医疗机构之间,社区卫生服务机构的自付比例和市级以上医院的自付比例较为接近。相同医疗机构内,城乡居民医保组的门诊自付费用和自付比例高于城镇职工医保组。除2009年之外,城镇职工医保组在市及以上医院住院的次均住院医疗费用为1-1.5万元左右,城乡居民医保组也基本处于这个水平。但城乡居民医保组的次均住院自付费用高于城镇职工医保组,前者为0.8～1.5万元左右,后者为0.4～0.5万元左右；城乡居民医保组的次均住院费用自付比例也高于城镇职工医保组,前者在50%以上,后者为30%左右。2009～2013年城镇职工医保组的家庭灾难性卫生支出发生率为11.2%-15.6%,城乡居民医保组为8.9%～12.7%,但两者间的差异没有统计学显著意义。6.老年人卫生服务利用和健康相关生命质量的影响因素两周就诊概率的Logistic回归结果显示,在控制其他因素不变的情况下,城乡居民医保组老年人发生就诊的可能性低于城镇职工医保组老年人发生就诊的可能性。性别和调查年份是城镇职工医保组门诊服务利用的影响因素,城乡居民组的模型中则没有一个解释变量的系数具有统计学显著意义,P值都大于0.05。住院概率的Logistic回归结果显示,在控制其他因素不变的情况下,城乡居民医保组老年人发生住院的可能性和城镇职工医保组老年人发生住院的可能性没有差异。年龄、家庭人均支出水平和慢性病患病情况是城镇职工医保老年人的住院影响因素,城乡居民医保组则只有慢性病患病情况是其住院影响因素。门诊医疗费用的半对数线性回归结果显示,控制其他因素后,城乡居民医保组和城镇职工医保组的门诊医疗费用水平没有差异。性别、家庭人均支出水平、门诊就诊机构和调查年份是城镇职工医保老年人门诊医疗费用的影响因素,受教育程度、慢性病患病情况、门诊就诊机构和调查年份是城乡居民医保老年人门诊医疗费用的影响因素。住院医疗费用的半对数线性回归结果显示,控制其他因素后,城乡居民医保组和城镇职工医保组的住院医疗费用水平没有差异。年龄和调查年份是城镇职工医保组住院医疗费用的影响因素；城乡居民医保组因为老年住院患者的例数较少,所以模型中全部解释变量的系数的P值都大于0.05。家庭灾难性卫生支出发生概率的Logistic回归结果显示,在控制其他因素不变的情况下,城乡居民医保组和城镇职工医保组发生灾难性卫生支出的可能性没有差异。城镇职工医保组中,家庭人数、两周就诊情况、一年内住院情况是发生家庭灾难性卫生支出的影响因素。城乡居民医保组中,只有家庭人数是灾难性卫生支出发生可能性的影响因素。EQ-5D指数得分和EQ-VAS得分的多因素线性回归结果显示,在控制了其他因素后,城镇职工医保组和城乡居民医保组的健康相关生命质量相同。城镇职工医保组内,健康相关生命质量的影响因素为年龄、婚姻状况、家庭人均支出水平、慢性病患病情况、两周患病情况、两周就诊情况、一年内住院情况和调查年份。城乡居民医保组内,健康相关生命质量的影响因素为年龄、家庭人均支出水平、两周患病情况、两周就诊情况、一年内住院情况和调查年份。结论与建议慢性病是老年人卫生服务利用的主要原因。杭州市老年人的门诊就诊机构和住院机构有着不同的选择倾向,主要的门诊疾病和住院疾病种类也不同。不同基本医疗只对老年人的门诊就诊概率具有影响,对住院概率没有明显影响,医保之间保障水平的差异较小。不同基本医疗保险组老年人的卫生服务利用影响因素不同。老年卫生服务的重点应在于慢性病综合防治。杭州市的基层医疗服务建设仍有较大提升空间,可以尝试向老年人开展多种形式与不同层次的社区服务。从当前的保障水平来看,杭州市未来可以建立统一的基本医疗保险制度,而医保基金的使用可以有所创新。
[Abstract]:Facing the challenge of aging population and the pressure of health service for the elderly, the city of Hangzhou, Zhejiang province has a certain social and economic basis to deal with. Hangzhou has established a complete basic medical security system. In 2011, the basic medical insurance of the urban residents, the new rural cooperative medical service was integrated into the basic medical insurance of urban and rural residents, and changed at the same time. The difference between different basic medical insurance, the change of basic medical insurance policy, the characteristics of different medical insurance people themselves may affect the use of health service for the elderly, but there is no evidence support. The purpose of this study is to hang out for 2009~2013 years. State and city household survey data, mastering the status of elderly residents, understanding the social demographic characteristics, economic conditions and health status of the basic medical insurance and basic medical insurance for urban and rural residents, analyzing the basic situation and changing trend of the use of outpatient service and the use of hospitalization services. The factors affecting the health service of the elderly people with different basic medical insurance in the former social environment provide reference for improving the health service utilization and promoting the health of the elderly. Through the literature review, the research on the health service of the elderly under the different basic medical insurance is guided. The household registration family of urban residents in Hangzhou is a general approach. Multistage stratified random sampling was conducted to obtain the basic personal situation of 2009~2013 year old people, two weeks' medical treatment, hospitalization, health self evaluation and family income and expenditure. The questionnaires were based on the fourth national health service questionnaire and adapted from the research purposes. In order to ensure the comparability of data, the five Hangzhou household survey methods were consistent and strict quality control measures were taken to ensure the comparability of data in Hangzhou. All verified household survey data were recorded with EpiData 3, and data cleaning, statistical description, and description were carried out with SPSS 17 and Excel 2010. Statistical analysis. There were stratified analysis, comparative analysis, multiple factor regression analysis, and so on. Significant test methods were analysis of variance, LSD-t test and Person chi square test. Results the basic situation of the 1. elderly population was 2009~2013 years' survey 837, 814, 843, 861 and 825, of which the number of elderly population was 755, respectively. People, 800 people, 859 people, 966 people and 967 people, each accounted for 26.4%, 29.3%, 31.5%, 33.6% and 33.6%. of the total population of the year. The proportion of elderly people who participated in medical insurance in cities and towns was basically between 75%-80%, and the proportion of old people who participated in urban and rural residents' medical insurance (medical insurance and NCMS) of urban and rural residents was between 15%-20% and total 95%. urban workers. The social demographic characteristics of the elderly people in the medical insurance group and the urban and rural residents were all consistent in five years, but the family economic situation of the elderly changed over time. After the adjustment of the consumer price index, the average annual growth rate of the per capita income of the two groups was 8.7% and 10.5% respectively, and the per capita household expenditure was 8.7%, respectively. 4.3%. the aged people in the medical insurance group of urban and town workers are always longer than the old people in the old medical insurance group of urban and rural residents, the proportion of men is more, the proportion of marriage is higher, the level of education is higher, and the per capita income level of the family is higher, but there is no statistically significant difference between the two groups of families and the health status of the elderly and the health service needs 2009 ~ 2009. In 2013, the prevalence rate of chronic diseases in medical insurance for urban workers was higher than that in urban and rural residents, the former was 70% to 80%, the latter was 50% to 60%, both were higher than the national level. During the investigation, the three kinds of chronic diseases with the highest prevalence rate of elderly people in different medical insurance groups were not changed, all were hypertension, heart disease and diabetes. The two of the elderly was two. The prevalence of weekly illness is also higher, the prevalence of medical insurance for urban workers is above 60% and the level of elderly people in large cities is equal. The prevalence of medical insurance for urban and rural residents is slightly lower. The EQ-5D index of the elderly in the medical insurance group and the urban and rural residents in urban and rural areas is 0.845 to 0.918, and EQ-VAS is obtained. The scores were 71.1 to 76.7, higher than the level of the elderly in the large urban areas of China. There was no significant difference between the EQ-5D index score of the elderly and the EQ-VAS score in the different medical insurance groups. The outpatient service needs of the elderly and the use of the medical insurance group within the town and the urban and rural residents, and the average of two of the 2009~2013 year old people in 2009~2013 years. The rates of weekly visits were 57% and 32.9% respectively. The difference between the two was statistically significant. The two week medical treatment rate in the medical insurance group for urban workers was higher than the level of the elderly in the large urban areas, while the medical insurance group in the urban and rural areas was lower than that. The medical insurance group of urban workers and workers in the first three two weeks also included heart disease. The first three of the medical insurance group of urban and rural residents included cold or gastrointestinal diseases in.2009 to 2013, the proportion of medical insurance for the elderly in the community health service institutions was about 50%-65%, while the corresponding proportion of the elderly people in urban and rural areas was slightly higher. The main reasons for the selection of the first consultation institutions for the aged from 60% to 75%. are close proximity and convenience. In the different medical insurance groups, the proportion of self medical treatment for the elderly is also higher, and the hospitalization needs of the.4. elderly people are generally in the medical insurance group of the urban workers and the urban and rural residents, and the 2009~2013 year old people are in the hospital. All the elderly people have the highest level of heart disease, and other diseases such as gastrointestinal disease, cerebrovascular disease, diabetes, cancer, lung disease, hypertension, and cataracts are the top three in all elderly people. In different years under the same basic medical insurance, the elderly hospitalization institutions are all the same. Although the proportion of the basic medical insurance to the municipal and above hospitals is lower than the other medical institutions, there is no obvious influence on the behavior of the elderly in the hospital. The average hospitalization of the elderly in the medical insurance group and the urban and rural residents in the medical insurance group and the urban and rural residents, the proportion of the hospitalized and inpatients Both the personal burden of medical expenses for.5. and the expenditure of household health services were adjusted by the consumer price index. The medical costs of the medical insurance groups in the community health service institutions were more than 200 yuan per year, including about 40~60 yuan, and the outpatient medical expenses of the city and above were 400 yuan. On the other hand, it paid about 90~130 yuan, and the outpatient medical expenses of the urban and rural residents' medical insurance group in the community health service institutions were less than 200 yuan, which paid about 40~80 yuan. The self payment ratio of the community health service institutions and the self payment ratio of the hospitals above the municipal level were close. The same medical institutions, urban and rural residents were in the same medical institutions. The cost and self payment ratio of the outpatient payment and self payment in the medical insurance group are higher than that of the medical insurance group of the urban workers. In addition to 2009, the average hospitalization expenses of the medical insurance group in the city and the above hospitals are about 1-1.5 ten thousand yuan, and the medical insurance group of urban and rural residents is also basically at this level. The staff medical insurance group, the former is about 0.8 to 15 thousand yuan, the latter is about 0.4 to 5 thousand yuan, and the proportion of the average hospitalization expenses of urban and rural residents is higher than that of the medical insurance group of urban workers, the former is more than 50%, the latter is about 30%.2009 to 2013, the incidence of disastrous health expenditure in the urban workers' medical insurance group is 11.2%-15.6%, and the urban and rural areas are in urban and rural areas. The residents' medical insurance group was 8.9% to 12.7%, but there was no significant difference between the two. The Logistic regression results of the two week treatment probability of health service and health related life quality of.6. elderly people showed that the possibility of visiting the elderly in the urban and rural residents' medical insurance group was less than that of the other factors. The sex and the survey year are the influencing factors of the use of the outpatient service in the medical insurance group for urban workers and town workers. There is no significant statistical significance in the model of the urban and rural residents' group, and the Logistic regression results of the P value are greater than the 0.05. hospitalization probability. In the case of constant factors, the possibility of hospitalization of the elderly people in the medical insurance group of urban and rural residents and the possibility of hospitalization in the medical insurance group for urban workers were not different. Age, the level of per capita expenditure and the condition of chronic diseases were the factors for the hospitalization of the elderly medical insurance in urban and rural areas, while the medical insurance group in urban and rural residents had only chronic diseases. A semi logarithmic linear regression analysis of the outpatient medical expenses showed that there was no difference in the level of out-patient medical expenses of the medical insurance group between urban and rural residents and the medical insurance group of urban and rural workers after controlling the other factors. The influencing factors of medical expenses, the education degree, the chronic disease condition, the outpatient service institution and the survey year are the factors affecting the outpatient medical expenses of the elderly medical insurance in urban and rural residents. The semi logarithmic linear regression results of the hospitalized medical expenses show that after the control of other factors, the medical insurance group of urban and rural residents and the hospitalization of the medical insurance group for urban workers and workers are in the hospital. There is no difference in the level of medical expenses. Age and year of investigation are the factors affecting the hospitalization expenses of the medical insurance group in urban and rural areas. The number of cases in the medical insurance group of urban and rural residents is less, so the P value of the coefficient of all the explanatory variables in the model is greater than the Logistic regression results of the probability of 0.05. family disastrous health expenditure. It showed that there was no difference in the possibility of disastrous health expenditure between the medical insurance group of urban and rural residents and the medical insurance group of urban and rural workers in the control of other factors. In the medical insurance group for urban and urban workers, the number of families, the two weeks of medical treatment, and the hospitalization in one year were the factors affecting the disastrous health expenditure of the family. The results of multiple factor linear regression of the.EQ-5D index score and the EQ-VAS score of the risk factors for the occurrence of disastrous health expenditure showed that the health related life quality of the medical insurance group of urban workers and the urban and rural residents was the same after controlling the other factors. The influencing factors were age, marital status, family per capita expenditure, chronic disease, two weeks of illness, two weeks' medical treatment, hospitalization and survey year. The factors affecting health related quality of life in urban and rural residents were age, family per capita expenditure, two weeks of illness, and two weeks of medical treatment. Hospitalization and investigation year in one year. Conclusion and suggested chronic diseases are the main reasons for the use of health services for the elderly. There is a different choice tendency in the outpatient department and hospital institution for the elderly in Hangzhou, the main outpatient diseases and the types of inpatient diseases are different. There is no obvious influence on the hospitalization probability and the difference of the level of health insurance between the medical insurance and the medical insurance. The factors that affect the health service of the elderly in the different basic medical insurance groups are different. The emphasis of the elderly health service should be on the comprehensive prevention and control of chronic diseases. The construction of basic medical services in Hangzhou still has a big promotion space, and it can try to be old. From the current level of protection, Hangzhou can establish a unified basic medical insurance system in the future, and the use of medical insurance funds can be innovative.
【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

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