中国城乡居民医疗服务需求与医疗保险研究

发布时间：2018-07-11 21:51

本文选题：医疗保险 + 医疗服务需求　；参考：《南开大学》2013年博士论文

【摘要】：为建立“人人享有基本医疗保障”制度,保证每个人不分地域、民族、年龄、性别、职业、收入水平,都能公平获得基本医疗卫生服务,实现“人人享有基本医疗卫生服务”的医疗卫生体系,我国的医疗卫生体制不断进行改革和完善。当前,随着我国基本医疗保险覆盖范围的扩大,覆盖城乡的全民医保体系已经基本形成。目前我国的基本医疗保障制度是以新型农村合作医疗、城镇居民基本医疗保险、城镇职工基本医疗保险和城乡医疗救助为主体,分别覆盖农村人口、城镇非就业人口、城镇就业人口和城乡困难人群,解决了部分人群医疗保险缺失的不公平问题。但是,另一方面,制度本身的设计随着实施的进一步深化也逐渐的暴露出诸多问题。由于城乡二元结构使得居民在健康水平、医疗服务的可及性、可得性存在较大差距。而不同医疗保险制度提供经济风险保护时,在医保缴费标准、待遇水平、保障范围、报销比例等设计方面方面存在较大差异。这有可能进一步拉大城乡居民对医疗服务的使用和需求差距,进而可能导致城乡居民健康水平更大差距。同时,基本医疗保险制度的新农合、城职保和城居保三大主体制度：新型农村合作医疗、城镇居民基本医疗保险和城镇职工基本医疗保险存在着制度交叉；不同的管理机构和管理体制造成了制度运行的低效率。本文正是基于以上研究背景,综合运用微观经济学、保险经济学、卫生经济学、计量经济学等方法,建立在医疗服务需求理论与医疗保险基本理论基础上,一方面,从宏观视角,描述性分析国际和国内不同医疗保险制度模式实施效果；另一方面,从微观视角,实证检验包括商业医疗保险在内的、不同类型的基本医疗保险对我国城乡居民医疗服务需求和使用的影响差异。本文首先运用微观经济学、保险经济学和卫生经济学基本理论,阐述了健康与医疗服务需求理论和医疗保险需求理论以及医疗保险对医疗服务需求的影响理论,然后分别从国外和国内研究文献中回顾总结医疗保险对治疗行为选择和医疗服务需求支出影响的实证研究结果。本文研究的重点是,利用2008年“中国健康与养老追踪调查(CHARLS)"截面数据,以45周岁以上的中老年人为研究对象,采用不同的计量方法,以新型农村合作医疗为参照组,估计不同类型的医疗保险包括：城镇职工基本医疗保险、城镇居民基本医疗保险、公费医疗和商业医疗保险以及其他类型的医疗保险,对我国城乡居民医疗服务需求和使用的影响,具体衡量指标包括个体是否治疗,治疗行为选择决策、医疗费用总支出决策和个人自付医疗费用支出决策的影响。本文的研究结果表明个体的健康状况、人口和社会经济特征等异质性因素对医疗服务需求都有显著影响。在控制了这些异质性因素以后,不同的医疗保险对个体医疗服务需求和使用的差异影响十分显著。具体分为以下三个方面：首先,利用Logit模型和Multi-Nominal Logit模型对个体治疗行为选择决策的估计结果来看,无论居民是否报告患病情况下,相比新型农村合作医疗,其他医疗保险都会提高个体治疗行为发生概率,尤其是商业医疗保险会显著提高治疗行为概率的44%；城镇职工医疗保险则会显著提高12%。其次,利用Heckman样本选择模型(two-part)对个体医疗费用总支出决策模型的估计结果看,在医疗支出发生概率方面,相比新型农村合作医疗,商业医疗保险会显著提高个体医疗支出发生概率的33%,城镇职工医疗保险则会显著提高9%。在医疗费用总支出大小方面,相比新型农村合作医疗,城镇居民医疗保险覆盖人群的个人医疗费用总支出会显著增加59%,即1844元(按平均医疗支出3111元计算)；而享有公费医疗的人群的医疗总支出会显著增加125%,即3895元(按平均医疗支出3111元计算)。同时,根据收入弹性的计算公式和计量回归结果得出全部样本的医疗支出的收入弹性为0.127。再次,利用两部分模型对个人自付医疗费用支出决策模型的估计结果看,第一,在个人自付医疗支出发生概率方面,相对新型农村合作医疗而言,商业医疗保险会降低个人自付医疗支出发生概率的2%。第二,在发生个人自付医疗费用支出情况下,相比新型农村合作医疗,商业医疗保险会显著降低个人自付医疗支出的26%,约533元(按照个人自付医疗费用支出平均2022元计算)；而城镇居民医疗保险覆盖人群的个人自付医疗支出会显著增加56%,约1131元(按照个人自付医疗费用支出平均2022元计算)。而城镇职工医疗保险和公费医疗并没有发现显著影响。第三,在个人自付医疗费用负担比例方面,不同医疗保险的影响也存在显著差异。相比新型农村合作医疗,享有公费医疗人群和城镇职工医疗保险覆盖人群的个人自付医疗负担比例都显著降低8%，，商业医疗保险和城镇居民医疗保险人群的个人自付医疗费用负担比例会更高,但都并不显著。因此,本文得出以下主要结论：在控制了个体健康状况、社会经济等特征的异质性因素后,不同保障水平和筹资水平的医疗保险对城乡居民的医疗服务需求的差异影响十分显著。从治疗行为选择决策来看,相比新型农村合作医疗,城镇职工医疗保险和商业医疗保险在改善和提高个体治疗行为方面起到了更为积极的作用。从医疗需求总支出方面来看,相比新型农村合作医疗,城镇职工医疗保险和商业医疗保险提高了医疗需求总支出发生概率,而城镇居民医疗保险和公费医疗却提高了个体医疗需求总支出大小。从个人自付医疗费用支出来看,相比新型农村合作医疗,商业医疗保险降低了个人自付医疗支出发生概率,同时也会显著降低个人自付医疗费用总支出；而城镇居民医疗保险的个人自付医疗费用支出显著更高；城镇职工医疗保险和公费医疗去显著降低个人自付医疗支出负担比例。这一研究结果表明,包括商业医疗保险在内的五种医疗保险中,公费医疗处于最好的地位,城镇职工居于次好地位,商业医疗保险则仅次于城职保,城镇居民医疗保险和新型农村合作医疗则处于相对较差的地位。首先,享有公费医疗的人群医疗费用支出最高且个人自付医疗负担最低；其次为城镇职工医疗保险,显著提高个体的治疗行为发生,并在提高医疗服务需求的同时,降低个人自付医疗负担；再次是商业医疗保险,也提高了个体的治疗行为,同时降低个人自付医疗支出发生和自付医疗总支出；而新型农村合作医疗和城镇居民医疗保险覆盖人群则处于相对较差的地位,治疗行为发生概率较低且医疗需求总支出也较低,但个人自付医疗负担较重。而城镇居民医疗保险的个人医疗需求总支出和个人自负医疗支出都显著高于新型农村合作医疗,但是个人医疗负担比例也相对较高。可见由于医疗保险制度本身设计差异,导致了原本基于城乡收入和健康不平等基础之上的个体医疗服务需求和使用的不平等,进一步加剧;而医疗服务需求和使用的不平等,会进一步拉大城乡居民健康的不平等和收入的不平等,最终会影响到整个社会经济发展和稳定。因此,应采取有效措施,缩小不同医疗保险制度之间保障水平的差异,并降低个人自付医疗费用负担,真正实现全体国民享有的公平的、平等的、有效的基本卫生服务,最终提高全体国民的健康水平。
[Abstract]:In order to establish the "basic medical security for all" system, and to ensure that everyone is able to obtain the basic medical and health services without dividing the region, nationality, age, sex, occupation and income level, the medical and health system of "basic medical and health services for all" is realized, and the medical and health system in our country is constantly reformed and perfected. With the expansion of the coverage of basic medical insurance in China, the national medical insurance system covering urban and rural areas has been basically formed. At present, the basic medical security system in China is based on new rural cooperative medical care, basic medical insurance for urban residents, basic medical insurance of urban workers and urban and rural medical assistance as the main body, covering rural population and Urban Non - urban medical insurance, respectively. The employment population, the urban employment population and the urban and rural people have solved the unfair problem of the lack of medical insurance for some people. However, on the other hand, the design of the system itself has gradually exposed many problems with the further deepening of the implementation. The two yuan structure of urban and rural areas makes the residents at a healthy level and the accessibility of medical services. There is a large gap in sex, while different medical insurance systems provide economic risk protection, there are great differences in medical insurance payment standard, treatment level, scope of insurance and reimbursement ratio. It is possible to further widen the use of medical services and the gap between urban and rural residents, and may lead to the health level of urban and rural residents. At the same time, the new rural cooperative medical insurance system of the basic medical insurance system, the three main body system of urban occupational insurance and city residence insurance: the new rural cooperative medical system, the basic medical insurance of urban residents and the basic medical insurance of urban workers and towns, and the different management institutions and management system have caused the low efficiency of the system operation.
Based on the above research background, this paper makes a comprehensive application of microeconomics, insurance economics, health economics, econometrics and other methods, which is based on the theory of medical service demand and the basic theory of medical insurance. On the one hand, from a macro perspective, it describes the implementation effect of different medical insurance systems in both international and domestic. From the micro perspective, this paper empirically examines the differences in the impact of different types of basic medical insurance on the medical service demand and use of urban and rural residents in China, including commercial medical insurance.
Based on the basic theories of microeconomics, insurance economics and health economics, this paper expounds the theory of health and medical service demand theory and medical insurance demand theory as well as the influence theory of medical insurance on medical service demand, and then reviews and summarizes the choice of medical insurance to treatment behavior from foreign and domestic research documents. The focus of this study is to estimate the different types of medical insurance by using the new rural cooperative medical service as the reference group, using the cross-sectional data of "China's health and pension tracking survey (CHARLS)" in 2008, using different measurement methods, using the cross section data of "China's health and pension tracking survey (CHARLS)" in 2008. It includes basic medical insurance for urban workers, basic medical insurance of urban residents, public medical and commercial medical insurance and other types of medical insurance, which affect the needs and use of medical service in urban and rural areas of our country. The specific measure includes the treatment of individual, the decision of choice of treatment behavior, the decision of the total expenditure of medical expenses and the total expenditure. The impact of personal payment on medical expenses.
The results of this study show that the individual health status, population and socioeconomic characteristics have significant influence on the medical service demand. After controlling these heterogeneity factors, different medical insurance has ten significant differences on the individual medical service demand and use, which are divided into the following three aspects:
First of all, using the Logit model and the Multi-Nominal Logit model to estimate the decision of individual treatment behavior selection, it is found that no matter whether the residents report the illness or not, compared with the new rural cooperative medical care, the other medical insurance will increase the probability of individual treatment behavior, especially the commercial medical insurance will significantly increase the probability of treatment behavior. 44%, the medical insurance of urban workers will be significantly improved by 12%.. Using the Heckman sample selection model (two-part) to estimate the decision model of the total expenditure of individual medical expenses, compared with the new rural cooperative medical service, the commercial medical insurance will significantly increase the probability of the occurrence of individual medical expenditure by 33%, The medical insurance of urban workers will significantly increase the total expenditure of 9%. in the total expenditure of medical expenses. Compared with the new rural cooperative medical service, the total expenditure of individual medical expenses of urban residents' medical insurance coverage will increase by 59%, that is 1844 yuan (according to the average medical expenditure of 3111 yuan). A significant increase of 125%, that is 3895 yuan (according to the average medical expenditure of 3111 yuan). At the same time, according to the calculation formula of the income elasticity and the regression results, the income elasticity of the medical expenditure of all the samples is 0.127. again. Using the two part model to estimate the individual self paid medical expense decision model, first, the personal self pay medicine. Compared with the new rural cooperative medical system, the commercial medical insurance will reduce the 2%. second of the probability of personal medical expenditure. Compared with the new type of rural cooperative medical care, the commercial medical insurance will significantly reduce the personal medical expenditure by 26%, about 533 yuan (according to the new rural cooperative medical service). According to an average of 2022 yuan for individual self paid medical expenses, the individual self payment of medical insurance coverage for urban residents would significantly increase by 56%, about 1131 yuan (according to an average of 2022 yuan per person's self paid medical expense). The medical insurance and public health care of urban workers did not have significant impact. Third There are significant differences in the impact of medical insurance on the proportion of medical expenses. Compared with the new type of rural cooperative medical care, the proportion of individual self paid medical burden to the public medical workers and the medical insurance coverage of urban workers has been significantly reduced by 8%. The personal self payment of the medical insurance and the medical insurance of urban residents The proportion of the cost of treatment will be higher, but it is not significant.
Therefore, this paper draws the following main conclusions: after controlling the heterogeneity of individual health status and social and economic characteristics, medical insurance with different level of security and level of financing has a significant impact on the difference of medical service demand between urban and rural residents. Workers' medical insurance and commercial medical insurance have played a more active role in improving and improving individual treatment behavior. From the total expenditure of medical demand, compared with the new rural cooperative medical system, urban workers' medical insurance and commercial medical insurance have improved the probability of the total expenditure of medical demand, and the medical insurance of urban residents and the medical insurance of urban residents. Compared with the new type of rural cooperative medical care, the commercial medical insurance reduces the probability of individual self paid medical expenditure, and also significantly reduces the total expenditure of individual self paid medical expenses. The cost of medical treatment is significantly higher; medical insurance and public health care for urban employees will significantly reduce the proportion of personal expenses for medical expenses.
The results show that, of the five kinds of medical insurance, including commercial medical insurance, public health care is in the best position, the urban workers are in the best position, the commercial medical insurance is second only to the urban occupational insurance, the urban residents' medical insurance and the new rural cooperative medical care are in a relatively poor position. The group medical expenditure is the highest and the personal medical burden is the lowest, the second is the medical insurance of urban workers, which significantly improves the individual's treatment behavior, and reduces the personal medical burden while improving the medical service demand. Again, it is the commercial medical insurance, which also improves the individual's treatment behavior and reduces the individual self paid medical treatment. The new rural cooperative medical care and the medical insurance coverage of urban residents are in a relatively poor position, the probability of the treatment behavior is low and the total expenditure of medical demand is low, but the personal medical burden is heavy. Personal expense is significantly higher than that of the new rural cooperative medical system, but the proportion of personal medical burden is relatively high.
It can be seen that the differences in the design of the medical insurance system have resulted in the unequal demand for and use of individual medical services based on urban and rural income and unequal health, and the inequality in the demand for medical services and the unequal use of medical services will further increase the inequality of health and income inequality between urban and rural residents, and ultimately, Therefore, effective measures should be taken to reduce the difference in the level of security between different medical insurance systems, reduce the burden of personal medical expense, and truly realize the fair, equal and effective basic health service enjoyed by all the citizens, and ultimately improve the health of all the people.
【学位授予单位】：南开大学
【学位级别】：博士
【学位授予年份】：2013
【分类号】：R197.1;F842.684

【参考文献】