城乡基本医疗保险参保者卫生服务利用公平性研究

发布时间：2018-09-18 18:16

【摘要】：研究背景卫生服务利用公平性是保证全社会成员获得公平、可及、有效的卫生服务,以达到健康的相对公平,是各国政府及国际组织在卫生领域追求的重要目标之一。为了消除中国城乡二元结构带来的医疗卫生服务的城乡差距,提高城乡居民卫生服务利用的公平性,2009年,我国提出初步实现城乡基本医疗保险行政管理的统一,积极探索整合城乡居民医保。之后,各地区不断探索实施统筹城乡居民基本医疗保险(简称:城乡基本医保)。以往对城乡基本医保的研究都集中在城乡基本医保的制度内涵、必要性和路径探索等方面,很少有针对城乡基本医保城乡参保居民的卫生服务利用公平性的研究的文献。因此,本研究具有非常重要的意义。研究目的测量城乡基本医保实施前后试点地区参保居民卫生服务利用公平性,并对实施前后参保居民卫生服务利用的公平性进行比较,了解样本地区城乡基本医保制度对参保居民卫生服务利用公平性的影响程度,多层次地探索实施前后城乡参保居民在经济排序下居民卫生服务利用不公平的来源,进而针对研究结果提出相关建议,为城乡基本医保的可持续发展提供有益参考。研究方法(1)资料收集方法定性资料的收集通过文献复习和访谈法获得。定量资料的主要来源为教育部人文社科青年基金项目“城乡基本医疗保障一体化背景下的卫生保健公平性及其分解研究”。城乡居民基本医保实施之前总共获得2395个有效数据,获得1534个有效数据。(2)资料分析方法本研究利用描述性统计、单因素卡方检验以及回归分析方法分析城乡基本医保实施前后样本地区不同参保居民健康状况及卫生服务利用情况,探索参保居民城乡基本医保实施前后居民卫生服务利用的影响因素。进而利用集中指数测量城乡参保居民卫生服务利用的公平性,并通过集中指数分解法探索其不公平的来源。研究结果(1)参保居民卫生服务利用情况在门诊卫生服务利用方面,城乡基本医保实施之前的两周就诊率为12.65%,实施之后为17.73%,提高了5.08%。在住院卫生服务利用方面,实施之前年住院率为7.43%,实施之后为13.56%,提高了6.13%。(2)参保居民卫生服务利用的影响因素经logistic回归方法分析发现,影响实施之前参保居民门诊卫生服务利用的因素有25岁~、40岁~、55岁~、两周患病、慢性病患病、小学及以下文化程度、婚姻状况和中高支出组,回归系数依次为-0.5690、-1.0667、-0.6440、2.2255、0.3847、0.4370、-0.2480、-0.8526。影响实施之后参保居民门诊卫生服务利用的因素有55岁~年龄组、两周患病、中等规模家庭、中低支出组、中支出组和中高支出组,其回归系数依次为:0.9281、-0.3050、-0.5748、0.5870、-0.9747、-0.5197。影响实施之前参保居民住院卫生服务利用的因素有40岁~、自评健康状况、慢性病患病、收入来源为务工、小规模家庭、中等规模家庭和中高支出组,其回归系数依次为-0.7943、-0.0697、-0.5602、-0.0564、-0.9888、-0.7307、-0.0898。影响实施之后参保居民住院卫生服务利用的因素有性别、自评健康状况、两周患病、慢性病患病情、婚姻状况、初中文化程度、小规模家庭,其回归系数依次为:-0.5750、1.367、-0.9213、-0.4858、0.8086、-1.0906、0.8419。(3)参保居民卫生服务利用的公平性城乡基本医保实施前后不同社会经济水平参保居民门诊卫生服务利用的集中指数分别为0.0963和-0.0783,水平不公平指数分别为0.0097和-0.1076;住院卫生服务利用的集中指数分别为0.0921和0.1157,水平不公平指数分别为0.1199和0.1925。(4)参保居民卫生服务利公平性的分解对城乡基本医保实施之前参保居民门诊卫生服务利用不公平的贡献最大的因素是年龄,贡献率为83.25%,对实施之后参保居民门诊卫生服务利用不公平的贡献为正且贡献最大的因素是经济因素,贡献率为169.56%;对实施之前参保居民住院卫生服务利用不公平的贡献为正向且贡献最大的因素是家庭规模,贡献率为47.54%,对实施之前参保居民住院卫生服务利用不公平的贡献为正向且贡献最大的因素是经济因素,贡献率为98.55%。结论样本地区城乡基本医保实施前后,参保居民的门诊和住院卫生服务都存在不同程度的不公平。门诊卫生服务利用在实施之前存在亲富的不公平,对其不公平贡献最大的是年龄因素;而实施之后则存在亲穷的不公平,对其不公平贡献最大的是经济因素。住院卫生服务利用实施前存在亲富的不公平,对其不公平贡献最大的是家庭规模;住院卫生服务利用实施后也存在亲富的不公平,不公平有所加剧,对其不公平贡献最大的是经济因素。以上因素均会增大卫生服务利用的不公平。建议1.不断完善城乡基本医保制度,促进筹资和补偿的合理性;2.控制住院医疗服务的医疗价格;3.提高门诊医疗服务的水平;4.通过城乡基本医保,引导家庭成员实现疾病风险共担。
[Abstract]:BACKGROUND Equity in health service utilization is one of the important goals pursued by governments and international organizations in the field of health in order to ensure that members of the whole society have access to fair, accessible and effective health services so as to achieve relative health equity. In 2009, China proposed to achieve the unification of the administration of basic medical insurance in urban and rural areas and actively explore the integration of medical insurance for urban and rural residents. In terms of the system connotation, necessity and Path Exploration of basic medical insurance in urban and rural areas, there are few literatures on the fairness of health service utilization of urban and rural residents with basic medical insurance. By comparing the fairness of health service utilization of the insured residents before and after the implementation of the system, the impacts of the basic medical insurance system in urban and rural areas on the fairness of health service utilization of the insured residents in the sample areas were understood, and the sources of unfairness in health service utilization of the insured residents before and after the implementation of the system were explored at different levels. Methods (1) Qualitative data were collected through literature review and interviews. The main source of quantitative data was the integration of basic medical insurance in urban and rural areas. A total of 2 395 valid data and 1 534 valid data were obtained before and after the implementation of basic medical insurance for urban and rural residents. To explore the influencing factors of health service utilization of the insured residents before and after the implementation of the basic medical insurance in urban and rural areas, and then to measure the equity of health service utilization of the insured residents in urban and rural areas by using the centralized index, and to explore the sources of the inequity by using the centralized index decomposition method. In the utilization of outpatient health services, the two-week visiting rate was 12.65% before the implementation of basic medical insurance in urban and rural areas, 17.73% after the implementation, and increased by 5.08%. In the utilization of inpatient health services, the annual hospitalization rate was 7.43% before the implementation, 13.56% after the implementation, and increased by 6.13%. Logistic regression analysis showed that the factors influencing the utilization of out-patient health services before implementation were 25-40-55 years old, two-week illness, chronic disease, education level of primary school and below, marital status and high expenditure group, and the regression coefficients were - 0.5690, - 1.0667, - 0.6440, 2.2255, 0.3847, 0.4370, - 0.2480, respectively. The factors influencing the utilization of out-patient health services were 55-year-old group, two-week-old disease, medium-sized family, low-middle expenditure group, middle-expenditure group and high-middle expenditure group. The regression coefficients were 0.9281, -0.3050, -0.5748, 0.5870, -0.9747, -0.5197. The factors influencing the utilization of in-patient health services of the insured residents before the implementation were 0.9281, -0.3050, -0.5870, -0.9747, -0.5197. The regression coefficients were - 0.7943, - 0.0697, - 0.5602, - 0.0564, - 0.9888, - 0.7307, - 0.0898. The factors influencing the utilization of hospitalized health services were gender, self-rated health status. The regression coefficients were - 0.5750, 1.367, - 0.9213, - 0.4858, 0.8086, - 1.0906, 0.8419. (3) Fairness of health service utilization of insured residents before and after implementation of basic medical insurance in urban and rural areas. The median index was 0.0963 and - 0.0783, and the level unfairness index was 0.0097 and - 0.1076, respectively. The concentration index of hospitalized health service utilization was 0.0921 and 0.1157, and the level unfairness index was 0.1199 and 0.1925 respectively. (4) The decomposition of the equity of health service benefits of insured residents before the implementation of basic medical insurance in urban and rural areas. Age was the biggest contributor to the unfair utilization of outpatient health services, accounting for 83.25%. Economic factors contributed the most to the unfair utilization of outpatient health services of insured residents, accounting for 169.56%. The unfair utilization of inpatient health services of insured residents contributed the most to the unfair utilization of inpatient health services. The major factor was family size, with a contribution rate of 47.54%. The economic factor contributed the most to the unfair utilization of hospitalized health services before the implementation, with a contribution rate of 98.55%. Unfair. Before the implementation of outpatient health services, there is unfair relationship between the rich and the parents, and the age factor contributes the most to the unfair. After the implementation, there is unfair relationship between the poor and the parents. The economic factor contributes the most to the unfair relationship between the rich and the parents. It is the family scale; the injustice between the rich and the dear also exists after the implementation of hospitalized health service utilization, which is aggravated by economic factors. The above factors will increase the unfairness of health service utilization. The medical price of service; 3. Improving the level of outpatient medical service; 4. Guiding family members to share disease risk through basic medical insurance in urban and rural areas.
【学位授予单位】：宁夏医科大学
【学位级别】：硕士
【学位授予年份】：2017
【分类号】：R197.1;F842.684

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