十四种重大疾病医疗保险住院费用分析与测算

发布时间：2018-07-23 10:20

【摘要】：[目的]通过分析湖北省典型地区城乡全部参保居民（职工医疗保险、居民医疗保险和新农合）十四种重大疾病住院医疗费用，构建测算方法，测算在不同保障范围以及政策建议补偿水平下，居民基本医疗保险保障特殊病种重大疾病所需资金量和重大疾病补充商业保险所需筹资的基数，讨论资金筹集与重大疾病保障体系构建的关系以及目前重大疾病保险政策的合理性，继而提出更有针对性的重大疾病保障筹资管理和体系构建的政策建议。 [方法]在文献研究的基础上，通过回顾性数据调查法，获取湖北省A城市2009年1月-2011年5月基本医疗保险（职工医疗保险、居民医疗保险和新农合）所有参保居民的基本信息、病种名称、住院费用及医保统筹费用等数据。在A城市选取2家具有重大疾病规范治疗水平的医疗机构，调查得到部分病种2009年1月-2011年5月医院病案管理信息系统中治疗费用和具体治疗方式信息。运用统计学分析法、反事实分析法、敏感度分析法、规范分析法等方法对所收集的数据和信息进行分析。 [结果]1.重大疾病治疗手段和费用特征：重大疾病需要手术、放疗、化疗、综合治疗等多种治疗方法，进行手术治疗的平均住院费用要高于其他治疗方式的平均总住院费用，但手术治疗的病例百分比相对较低（17.7%）。 2．重大疾病患者住院总费用分布与构成：（1）重大疾病患者住院总费用呈偏态分布，平均住院费用9401.09元，77.5%的住院病人费用在10000元以内；（2）脑梗死、肺癌和胃癌占重大疾病病种住院总费用构成前三位；（3）在新农合住院总费用构成中，药品费和治疗费所占比例最高，分别为48.0%和19.3%，目录外药品占22.7%。 3.重大疾病人年住院费用分析：（1）重大疾病人年平均住院费用为13223.30元，人年住院费用在10000元以下的占69.0%；（2）与湖北省新增重大疾病医药费用限额标准相比，虽然限额能覆盖大部分手术病例的费用，但至少25%的恶性肿瘤患者人年费用超过病种限额。同时手术等特殊治疗方式的病例比例较低。 4.重大疾病服务利用与就医流向分析：（1）重大疾病平均年住院人次占该地平均年住院人次的4.7%，住院人次随着医疗机构级别的升高而增加，新农合3级医疗机构的住院人次比例最低（62.2%），城镇职工基本医疗保险最高（82.4%）；（2）重大疾病市外住院人次占住院总人次比例为21.3%，其中新型农村合作医疗市外就医比例最低（19.6%），职工医疗保险市外就医比例最高（25.9%）。 5.重大疾病基本医疗保险补偿情况：（1）重大疾病的实际补偿比为52.3%，其中新农合的实际补偿比最低（35.5%），城镇职工补偿比最高（70.5%）；（2）新农合实际报销比例在3级医疗机构仅31.3%；相比城镇职工在3级机构报销比例70.5%；（3）市外住院报销比例为44.3%，市内为59.3%。新农合重大疾病市外住院实际报销比例最低（20.5%）；城镇职工市外住院补偿比例最高（66.8%）。 6.十四种重大疾病保险测算：（1）经测算可得当地农村重大疾病医疗保险达到政策建议水平(70%)需增加基本医疗保险资金341.11万元，人均4.74元;城市需282.93万元，人均8.08元。新农合所需资金增量占当地2010年年度筹资总额的3.5%，占支出总额的4.4%。（2）按标准对新农合部分病种手术治疗等过程实施保障，测算得到资金的增加量为127.81万元。 7.新农合重大疾病筹资-补偿比敏感度分析：随着农村十四种重大疾病病种的保障水平的提高，补偿比每升高1%，基本医保所需要资金相对需要增加0.10%-0.11%。 8.补充商业医疗保险筹资基数测算：对城乡居民重大疾病基本医疗保险补偿后个人负担费用按标准分段赔付，不受病种限制，重大疾病商业补偿保险的筹资基数为928.65万元，，人均8.68元。 [结论]1如果仅对手术等的特殊治疗方式进行补偿，可能会导致大部分其他治疗方式的高费用重大疾病患者得不到保障，降低了资金的使用效率。 2对A城市十四种重大疾病全过程治疗方式的保障水平提高到70%是可行的。 3重大疾病患者的医疗机构利用和基本医疗保险补偿存在明显的城乡差异，应优先对农村重大疾病进行保障。 4补充商业保险的人均筹资基数8.68元占全省指导性筹资标准34.7%。表明指导筹资标准理论上可以满足重大疾病保障的资金需求。 5各地区应对重大疾病保险费用进行测算，根据自身经济水平与管理能力，建立适宜当地社会发展水平的重大疾病医疗保障制度。
[Abstract]:[Objective] by analyzing the hospitalization expenses of fourteen major diseases in the urban and rural areas of Hubei Province, all the residents (medical insurance, medical insurance and nncms) were built, and the calculation method was constructed to calculate the basic medical insurance for the major diseases of special diseases under the different scope of guarantee and the compensation level of policy recommendations. Gold and major diseases supplement the base of financing for commercial insurance, discuss the relationship between fund raising and the construction of major disease guarantee system, and the rationality of the current insurance policy for major diseases, and then put forward more targeted suggestions for the management and construction of major disease guarantee fund management and system construction.
[Methods] on the basis of literature research, through the retrospective data survey method, the basic information of all the residents of the basic medical insurance (staff medical insurance, resident medical insurance and nncms) in A city of Hubei province January 2009 -2011 year, the name of disease species, the cost of hospitalization and the overall cost of medical insurance were obtained. In the city of A, 2 furniture were selected. The medical institutions of the standard treatment level of major diseases were investigated for the treatment cost and specific treatment information in the hospital medical records management information system in May -2011 year January 2009. The data and information were analyzed by means of statistical analysis, anti fact analysis, sensitivity analysis, and normative analysis.
[results]]1. major disease treatment means and cost characteristics: major diseases require surgery, radiotherapy, chemotherapy, comprehensive treatment and so on. The average cost of hospitalization for surgical treatment is higher than the average total hospitalization expenses of other treatments, but the percentage of surgical treatment is relatively low (17.7%).
The total cost distribution and composition of 2. patients with major diseases were as follows: (1) the total cost of hospitalization was partial distribution, the average hospitalization cost was 9401.09 yuan, and the cost of hospitalized patients in 77.5% was less than 10000 yuan; (2) cerebral infarction, lung cancer and gastric cancer accounted for the first three in the total cost of hospitalization for major diseases; (3) the total cost of hospitalization in NCMS. The highest proportion of drug fees and treatment fees was 48% and 19.3% respectively, and the drugs outside the list accounted for 22.7%.
3. analysis of the cost of hospitalization for the year of major diseases: (1) the average annual hospitalization cost of major diseases was 13223.30 yuan, and the annual hospitalization cost of the person was less than 10000 yuan. (2) compared with the medical cost limit standard of major new diseases in Hubei Province, although the limit could cover the cost of the cases of the major breakup, at least 25% of the malignant tumor patients were in the human year. The cost exceeds the limit of disease and the proportion of cases with special treatment such as surgery is low.
4. the analysis of service utilization and medical treatment flow of major diseases: (1) the average annual hospitalizations of major diseases accounted for 4.7% of the average annual inpatient number, the number of inpatients increased with the level of medical institutions, the ratio of the number of inpatients in the new NCMS 3 level medical institutions was the lowest (62.2%), the basic medical insurance of urban workers (82.4%); (2) major diseases. The proportion of inpatients outside the city is 21.3%, of which the proportion of the new rural cooperative medical service is the lowest (19.6%), and the proportion of medical insurance for workers and workers outside the city is the highest (25.9%).
5. the basic medical insurance compensation of major diseases: (1) the actual compensation ratio of major diseases is 52.3%, of which the actual compensation ratio of nncms is the lowest (35.5%), the compensation ratio of urban workers is the highest (70.5%); (2) the actual reimbursement ratio of the NCMS is only 31.3% in the 3 level medical institutions; compared with the urban workers in the 3 level institution reimbursement ratio 70.5%; (3) out of the city hospital. The proportion of reimbursement was 44.3%, and the actual rate of reimbursement in the city outside the city was the lowest (20.5%) for 59.3%. NCMS, and the proportion of urban workers and workers outside the city was the highest (66.8%).
6. insurance estimates for fourteen major diseases: (1) it is estimated that the level of medical insurance for major diseases in the rural areas can be reached to the level of policy recommendations (70%) to increase basic medical insurance funds by 3 million 411 thousand and 100 yuan and 4.74 yuan per capita; the city needs 2 million 829 thousand and 300 yuan and 8.08 yuan per person. The capital increase of the NCMS accounts for 3.5% of the annual total annual fund-raising in 2010, accounting for total expenditure. The amount of 4.4%. (2) is guaranteed according to the standard, and the amount of capital increase is 1 million 278 thousand and 100 yuan.
7. new NCMS major disease financing and compensation ratio sensitivity analysis: with the improvement of the level of fourteen major diseases in rural areas, the compensation ratio is 1%, and the required funds for basic medical insurance need to be increased by 0.10%-0.11%.
8. supplement the financing base of commercial medical insurance: the individual burden on the basic medical insurance compensation for the major diseases of urban and rural residents is paid according to the standard subsection, and it is not restricted by the disease. The financing base of the commercial compensation insurance for major diseases is 9 million 286 thousand and 500 yuan and 8.68 yuan per person.
[conclusion if]1 only compensates for special treatment, such as surgery, most of the other treatments may not be guaranteed for the high cost of the disease and reduce the efficiency of the use of funds.
2 it is feasible to increase the level of treatment for fourteen major diseases in A city to 70% in the whole process.
3 there are obvious differences between urban and rural areas in the utilization of medical institutions and the compensation for basic medical insurance in major diseases. Priority should be given to the protection of major diseases in rural areas.
4 the per capita fund-raising base of commercial insurance is 8.68 yuan (34.7%.), which accounts for the province's guiding fund-raising standard, which shows that the fund raising standards can theoretically meet the demand for funds for the guarantee of major diseases.
5 each area should measure the insurance costs of major diseases and establish a medical security system for major diseases suitable for the level of local social development according to its own economic level and management ability.
【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】：F842.684

【参考文献】