新型农村合作医疗制度的调研分析与绩效评价

发布时间：2018-06-16 13:28

本文选题：新型农村合作医疗制度 + 评价指标体系　；参考：《辽宁大学》2013年博士论文

【摘要】：我国农村居民在传统农村合作医疗制度瓦解、新型农村合作医疗制度建立之前一直处于无社会医疗保障状态，就医时发生的医疗费用主要由农民个人负担，到上个世纪90年代末，医疗费用的增长速度远远超过农村居民收入的增长速度，尤其是患大病时，他们不堪医疗费用的重荷，其最终结果往往是农村居民因病致贫。农民看病难、看病贵，致使身体健康状况下降，严重影响我国农村人力资本的积累与社会稳定。针对这种情况为扭转我国农村居民的就医困境，2003年开始，我国先以部分省市的农村为试点建立以“大病统筹”为主的“新型”农村合作医疗制度和医疗救助制度（简称新农合）。该医疗制度是由政府组织、引导、支持，农民自愿参加，个人、集体和政府多方筹资，以大病统筹为主的农民医疗互助共济制度①，是我国各地农村正在推行的一项农村医疗保障制度，是促进社会公平、协调发展、惠及七亿六千万农村人口的战略性政策，对于缩小城乡差距、扭转不平衡的社会发展结构、构建和谐社会具有深远的意义。本篇论文的写作目的是考察新农合制度的实施绩效，并分析其存在的主要问题，以期为完善新农合制度做出应有的贡献。为了实现论文的写作目的，笔者通过对辽宁、吉林、山东、河南四省参合农民的问卷调查与实地走访调研，掌握了新农合制度运行的实际情况和论文写作的一手资料。在此基础上进行了论文的框架设计和写作。论文的主要内容如下：第一，论文的理论基础。首先，，系统梳理与客观评价了国内外学者对农村医疗保障问题的研究成果。包括国外学者对农村医疗保障制度运行、农村医保制度对防范疾病风险的作用、政府在医疗保障中的作用及干预失灵等问题的研究；国内学者对我国新农合制度的建设、筹资、医疗补偿、基金分配，以及农村合作医疗制度建设的国际经验等方面的研究。并对国内外学者的研究成果进行了客观评价。现有的相关研究成果不仅为本论文的研究提供了知识基础和参考借鉴，现有理论的研究不足也构成了本文的研究重点。其次，概括阐述了社会公平理论、信息不对称理论、利益集团理论、帕累托效率理论和纳什均衡理论，从而为本文在评价指标选取、问题成因分析提供了理论依据。第二，新型农村合作医疗制度实施绩效研究。首先，介绍了作者对新农合制度调研的基本情况，并对调研数据与调研结果进行了整理、分析；其次，根据社会保障的生存公平与劳动公平理论和我国城乡医疗保障的实际情况，建立了新农合制度绩效评价指标体系，对各项指标赋以不同的权重，并依据调研的一手资料和官方统计资料对新农合制度的实施绩效进行了客观评价；最后根据绩效评价结果探讨了新农合制度存在的主要问题，即：新农合的筹资水平低、保障病种范围受限、转诊制度不完善、监督与管理不到位、新农合的定点医疗机构技术水平低下等。这些问题的存在使参合农民的就医需求难以得到满足，与新农合制度的设计初衷相矛盾。第三，新型农村合作医疗制度存在问题的原因分析。以信息不对称理论、利益集团理论、帕累托效率理论、纳什均衡理论为基础，通过对新农合制度设计、运行与管理的出资责任、监督与管理等方面的博弈分析，剖析了新农合制度存在问题的原因。新农合制度实施中存在诸多问题，都与制度设计的先天不足直接相关。新农合低水平保大病制度的安排不仅不能满足于农民大病小病全保的利益诉求，更与农村定点医疗机构的选择相矛盾。这一矛盾又派生了限制性转诊制度，并由此引发了农民工就医难及患大病农民转诊难等新问题。由于新农合制度的运行管理及其所需资金均由地方政府负责，但业绩考核却依然是GDP导向，使得地方政府对新农合制度运行管理的财权与事权不配套、责权利不统一，从而导致地方政府既缺乏对新农合制度运行管理的内在动力，又没有对新农合制度进行有效监督与管理的足够财力。在政府监管不到位的条件下，定点医疗机构过度医疗、参合农民与定点医疗机构合谋套用新农合资金的情况时有发生。而保大病的合作医疗制度、农村定点医疗机构的选择、新农合制度运行管理责任与出资的制度安排，不仅与中国现阶段经济发展水平低的国情有关，更取决于制度博弈参与双方的博弈力量对比。第四，完善新型农村合作医疗制度对策研究。“哲学家只是用不同的方法解释世界，而问题在于改变世界”。①论文针对新农合制度存在的问题及其成因，借鉴国外日本、英国、德国的农村医疗保险制度在资金筹集、就医方式、农村医疗水平提升等方面的经验，提出了完善新农合制度的对策建议，主要有：为新农合制度立法；加大政府对新农合制度运行的资金投入；提高定点医疗机构的服务水平；完善就医转诊制度；加强对新农合制度运行的监督与管理。
[Abstract]:China's rural residents have disintegrated in the traditional rural cooperative medical system, and the new rural cooperative medical system has been in the state of non social medical security before the establishment of the new rural cooperative medical system. The medical expenses occurred mainly by the individual farmers. By the end of the 90s of last century, the growth rate of medical expenses was far more than the growth rate of rural residents' income. Especially in the case of serious illness, they are not able to bear the burden of medical expenses. The final result is that the rural residents are poor. The farmers are difficult to see the disease, and the health conditions are expensive. The health status of the rural residents is declining, and the accumulation of human capital and social stability in rural areas are seriously affected. In order to reverse the dilemma of rural residents in China, this situation began in 2003, In China, the "new type" rural cooperative medical system and medical assistance system (nncms) are set up in the rural areas of some provinces and cities as a pilot project. The medical system is organized by the government, guided, supported, voluntary participation of farmers, individual, collective and government fund-raising, and the mutual assistance of farmers with major diseases as a co-ordinate. The Freemasonry system is a rural medical security system which is being carried out in rural areas of China. It is a strategic policy to promote social fairness, coordinate development and benefit the seven hundred and sixty million rural population. It has far-reaching significance for reducing the gap between urban and rural areas, reversing the unbalanced social development structure, and building a harmonious society.
The purpose of this paper is to investigate the implementation performance of the new rural cooperative system and analyze its main problems in order to contribute to the improvement of the new rural cooperative system. In order to achieve the purpose of writing the paper, the author has grasped the new farmers through the survey and field visits of the farmers in the four provinces of Liaoning, Jilin, Shandong and Henan. On the basis of the actual situation of the system operation and the first-hand information of the thesis writing, the framework of the thesis is designed and written. The main contents of the paper are as follows:
First, the theoretical basis of the thesis. First, it systematically reviews and objectively evaluates the research results of domestic and foreign scholars on rural medical security, including the operation of rural medical security system by foreign scholars, the role of rural medical insurance system on preventing the risk of disease, the role of government in medical security and the failure of intervention, and so on; The internal scholars have studied the construction, financing, medical compensation, fund distribution, and the international experience of the construction of rural cooperative medical system in China, and made an objective evaluation on the research results of scholars at home and abroad. The lack of theoretical research also constitutes the focus of this study. Secondly, it summarizes the theory of social equity, information asymmetry theory, interest group theory, Pareto efficiency theory and Nash equilibrium theory, thus providing a theoretical basis for the selection of evaluation indicators and the analysis of the causes of the problems.
Second, the implementation of the new rural cooperative medical system performance research. First, the author introduced the basic situation of the investigation of the new rural cooperative system, and analyzed the survey data and research results. Secondly, according to the theory of social security and the theory of labor equity and the actual situation of urban and rural medical security in our country, the new rural cooperative system was established. The system performance evaluation index system is assigned to various indexes with different weights, and the implementation performance of the new rural cooperative system is evaluated objectively according to the one hand data and official statistics. Finally, the main problems of the new rural cooperative system are discussed according to the results of performance evaluation, that is, the financing level of the new rural cooperative system is low and the disease species is guaranteed. Limited scope, imperfect referral system, inadequate supervision and management, low technical level of the designated medical institutions of the NCMS, and so on. The existence of these problems makes it difficult to meet the demand for medical treatment of the participating farmers, and contradicts the original intention of the new rural cooperative system.
Third, the cause analysis of the problems in the new rural cooperative medical system. Based on information asymmetry theory, interest group theory, Pareto efficiency theory and Nash equilibrium theory, this paper analyzes the problems of the new rural cooperative system through the game analysis on the design of the new rural cooperative system, the responsibility of operation and management, supervision and management and so on. The reasons. There are many problems in the implementation of the new rural cooperative system, which are directly related to the deficiency of the system design. The arrangement of the new NCMS low level protection system is not only not satisfied with the interest demands of the farmers with large diseases and small diseases, but also contradicts the choice of the rural designated medical institutions. This contradiction also derives the restrictive referral system, As a result, the operation management of the new rural cooperative system and the funds needed are all responsible for the local government, but the performance assessment is still GDP oriented, which makes the local government do not match the financial power and power of the operation and management of the new rural cooperative system, and the responsibility is not unified, thus leading to the ununification of the power and the power. The local government has not only the inherent motive force for the operation and management of the new rural cooperative system, but also has no sufficient financial power to supervise and manage the new rural cooperative system effectively. Under the condition of the government supervision is not in place, the excessive medical treatment of the designated medical institutions and the conspiracy to conspire with the farmers and the fixed-point medical institutions have occurred when the new rural cooperative funds are conspire. The cooperative medical system, the choice of rural fixed-point medical institutions and the system arrangement of the operation management responsibility and capital contribution of the NCMS system are not only related to the situation of the low level of China's economic development at the present stage, but also on the game strength comparison between the two parties involved in the system game.
Fourth, to improve the Countermeasures of the new rural cooperative medical system. "Philosophers only explain the world in different ways, but the problem is to change the world." (1) the paper aims at the problems and causes of the new rural cooperative system, and draws lessons from the rural medical insurance system in Japan, Britain and Germany for the fund raising, medical treatment, and rural medical water. On the other hand, some suggestions were put forward to improve the new rural cooperative system, including the legislation of the new rural cooperative system, the increase of the government's investment in the operation of the new rural cooperative system, the improvement of the service level of the designated medical institutions, the improvement of the medical referral system, and the supervision and management of the operation of the new rural cooperative system.
【学位授予单位】：辽宁大学
【学位级别】：博士
【学位授予年份】：2013
【分类号】：F323.89;F842.684;R197.1

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