新农合高费用住院病人保障水平及其影响因素分析

发布时间：2018-06-17 02:17

本文选题：新型农村合作医疗 + 高费用住院病人　；参考：《华中科技大学》2013年硕士论文

【摘要】：研究目的在对新农合高费用住院病人保障水平现状进行初步总结的基础上，分析新农合高费用住院病人保障水平的影响因素和保障水平偏低的根本影响原因，并对其中部分重要影响因素进行重点探讨，为新农合提高高费用住院病人保障水平，切实降低农民就医自付费用提供政策依据。研究方法通过机构调查法获取广西H、L两县2009-2011年新农合基本运行情况资料及H县2011年、L县2009-2011年新农合住院病人费用数据，在此基础上运用统计学分析、反事实分析、敏感度分析和卫生系统诊断树研究法对相关数据和资料进行分析。研究结果 1.H县2011年、L县2009-2011年高费用住院病人平均实际补偿比分别为41.62%、36.09%、33.68%和38.05%(均低于全县平均水平，且差异均具有统计学意义)；平均个人自付费用分别为各县当年农民人均纯收入的4.14、2.63、2.76和3.09倍；平均补偿范围内费用所占比分别为73.97%、90.48%、90.14%和89.47%(均低于全县平均水平，且差异均具有统计学意义)。不同病种的高费用住院病人实际补偿水平比较中尿毒症的平均实际补偿比最高（51.25%），高出其余四个病种10个百分点左右（差异均有统计学意义）。（不包含二次补偿） 2.2011年两县实施的二次补偿政策明显提高了高费用住院病人平均实际补偿比，，H、L两县平均实际补偿比分别提高了8.00%和14.21%，平均个人自付费用分别降低了13.71%和22.93%（差异均具有统计学意义）。 3.名义补偿比、补偿范围内费用所占比、就诊医疗机构层级、病种、住院总费用、住院天数和新农合补偿封顶线是新农合高费用住院病人保障水平的影响因素，其中名义补偿比、补偿范围内费用所占比和就诊医疗机构层级是关键因素。 4.模拟两县新农合高费用住院病人在本课题所界定的高费用标准以上的部分费用的平均名义补偿比提高到70%（模拟一），平均实际补偿比提高到70%（模拟二），高费用住院病人中个人自付费用高于上年农民人均纯收入的病人补偿范围内的个人自付费用降低50%（模拟三）以及高费用住院病人平均个人自付费用降低到上年农民人均纯收入的一倍四种情况（模拟四）时所需新增资金量，H县所需新增基金量占2011年基金筹资总额的比例分别为2.17%、8.00%、7.80%、29.91%,L县分别为5.32%、8.06%、12.39%和26.94%。综合来看，模拟一和模拟三可行性较大，模拟二和模拟四可行性较小。 5.从新农合筹资、支付、组织、规制和行为等五方面看，两县新农合高费用住院病人保障水平偏低的根本影响原因可归纳为政府投入不足、个人筹资有限，新农合管理者能力不足，监管能力有限、措施不足，支付方式改革滞后等。研究结论 1.高费用住院病人整体保障水平偏低，疾病经济风险大，保障水平亟待提高。 2.新农合二次补偿能有效提高高费用住院病人保障水平，但政策实施的公平性较差，应推进建立城乡居民大病保险，将现有二次补偿过渡到规范的大病保险。 3.两县应适当提高县级以上医疗机构名义补偿比，同时考虑优先对部分成本效益较高的重大疾病病种给予较高名义补偿比，并对超过一定费用标准的住院病人实施特殊补偿政策；完善双向转诊制度，住院转诊制度在规范上转的同时应特别注重向下转诊的设计；重点加强县级医疗机构在费用较高，但技术较为成熟的治疗项目的发展；增强对医疗机构服务的监管，优先将重大疾病治疗中成本效益较高，临床应用相对成熟且尚未在报销目录中的治疗项目和药品纳入补偿范围。 4.为保证高费用住院病人保障水平的稳步提升，经济层面上应继续大力提高新农合的筹资额度，同时，应积极推进按病种付费等支付方式改革，如对部分费用高，但费用分布较稳定的重大疾病病种实行定额付费方式。 5.不同地区高费用住院病人保障水平存在一定差异，具体地区应具体分析。
[Abstract]:research objective
On the basis of a preliminary summary of the current situation of the high cost inpatient guarantee level of NCMS, this paper analyzes the factors affecting the level of inpatient guarantee and the underlying causes of the low level of inpatient guarantee, and focuses on some important influencing factors to improve the level of the high cost inpatient guarantee for the NCMS. To reduce the farmers seeking self to provide policy basis for payment.
research method
The basic operation data of Guangxi H, L two county new rural cooperation (nncms) and the data of hospitalized patients in H County for 2009-2011 years in 2011 and L county were obtained by the method of institutional investigation. On this basis, statistical analysis, anti fact analysis, sensitivity analysis and health system diagnosis tree research method were used to analyze the related data and data.
The results of the study
In 1.H County, in 2011, the average actual compensation ratio of high cost hospitalized patients in L County for 2009-2011 years was 41.62%, 36.09%, 33.68% and 38.05% respectively (all were lower than the county average, and the difference was statistically significant); the average personal self payment was 4.14,2.63,2.76 and 3.09 times of the per capita net income of the peasants in the year of each county, and the cost within the average compensation range was within the range of average compensation. The percentages were 73.97%, 90.48%, 90.14% and 89.47% respectively (all were lower than the average level of the whole county, and the differences were all statistically significant). The average compensation ratio of uremia in the high cost hospitalized patients with different diseases was the highest (51.25%), and the other four diseases were 10 percentage points higher (the difference was statistically significant). Does not contain two times compensation)
The two compensation policies implemented in two counties in 2.2011 years obviously improved the average real compensation ratio of high cost hospitalized patients. The average real compensation ratio of H and L two counties increased by 8% and 14.21% respectively. The average personal self payment cost was reduced by 13.71% and 22.93% respectively (the difference was statistically significant).
3. nominal compensation ratio, the ratio of cost within the range of compensation, medical institution level, disease species, total hospitalization expenses, hospital days and CCF compensation capping line are the factors affecting the level of inpatient guarantee in the new CCMS high cost, of which the ratio of nominal compensation, the ratio of expenses within the scope of compensation and the level of medical institutions are the key factors.
4. the average nominal compensation ratio of the high cost standards above the high cost standard defined by the two county new NCMS patients is increased to 70% (simulation one), the average real compensation ratio is increased to 70% (simulation two), and the personal self payment of high cost inpatients is higher than the compensation range of the per capita net income of the farmers in the previous year. The cost of personal self payment was reduced by 50% (simulation three) and the average personal self payment of hospitalized patients was reduced to one of the four cases (simulation four) of the per capita net income of farmers in the previous year (simulation four). The proportion of new funds required for H County in 2011 was 2.17%, 8%, 7.80%, 29.91%, and 5.32%, 8., respectively, L County, respectively. 06%, 12.39% and 26.94%., a simulation and Simulation of three large and two feasibility simulation, simulation four feasibility of small.
5. from the five aspects of the NCMS financing, payment, organization, regulation and behavior, the basic factors affecting the low level of the high cost inpatient guarantee in two counties can be summarized as lack of government input, limited personal financing, lack of ability of the new rural cooperative management, limited supervision ability, insufficient measures and lagging reform of payment methods.
research conclusion
1. the high cost of hospital patients overall security level is low, the disease economic risk, security level needs to be improved.
The two compensation of 2. NCMS can effectively improve the level of high cost inpatient guarantee, but the fairness of the policy implementation is poor. It is necessary to promote the establishment of urban and rural residents' big disease insurance, and transfer the existing two compensation to the standard disease insurance.
3. the two counties should appropriately improve the nominal compensation ratio of the medical institutions at the county level and above, and consider giving priority to the higher nominal compensation ratio for some major diseases with higher cost and benefit, and implementing special compensation policies for inpatients with more than a certain cost standard; perfect two-way referral system, and the transfer of hospitalized referral system at the same time Special attention should be paid to the design of downward referral; the development of county-level medical institutions with higher costs but more mature treatment projects; the enhancement of the supervision of medical services; priority will be given to higher cost benefits in the treatment of major diseases, and the clinical application is relatively mature and has not yet been included in the reimbursement list of treatment projects and drugs. The scope of compensation.
4. in order to ensure the steady improvement of the security level of high cost hospitalized patients, we should continue to improve the financing amount of the NCMS at the economic level. At the same time, we should actively promote the reform of payment according to the payment of disease types, such as the payment method for the major diseases and diseases with higher cost but more stable distribution of cost.
5. different areas of the high cost of hospital patient security level has certain differences, specific analysis should be specific areas.
【学位授予单位】：华中科技大学
【学位级别】：硕士
【学位授予年份】：2013
【分类号】：R197.1

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