河南省新农合费用控制政策的研究报告

发布时间：2018-12-06 16:06

【摘要】：河南省的农业人口占全省人口的70%以上,自从2003年推行新型农村合作医疗以来,河南省已有98.27%的人参与了此项保障,新型农村合作医疗十年间为数十万计的新农合患者提供了数十亿计的新农合报销补偿金,然而,于此同时,新型农村合作医疗保障基金的合理使用问题凸显了出来,人均报销补偿金额越来越高,新型农村合作医疗保障基金的透支风险不断增加。为了防范新型农合医疗保障基金的透支可能,提高基金的使用效率,河南省卫生厅联合河南省财政厅等相关单位于2012年6月推出了新型农村合作医疗费用控制改革政策,旨在通过预付分级的、定量的金额给每个参合定点医疗机构,在就诊人数保持不变甚至提高的情况下,降低人均报销补偿金额,同时限定新型农村医疗保障报销目录外的用药比例和治疗比例,避免新农合患者自费金额过高。本文选取了河南省两家综合型公立医院R院和Z院作为研究对象,通过收集整理这两家医院2011年-2013年的医疗数据和河南省卫生厅农卫处的考评数据,比较两家医院在控费政策实施前后的业务量和各种相关参数,对控费政策的实施效果,特别是存在的问题以及造成这些问题的原因进行分析和探讨,并在此基础上提出进一步完善费用控制政策及其执行的建议。通过分析发现,本次费用控制政策在刚实施半年的过程中,确实起到了应有的作用,新农合患者的费用增长速度减缓,药费占总费用的比例出现了明显的下降,较好的达到了河南省卫生厅的预期目标。然而,在之后的一年中,新农合患者的费用又呈现了大幅度提高的问题。造成这些问题的原因。首先在于公立医院体制上的矛盾,导致了公立医院公益性的淡漠,逐利性增强；其次,在政策执行过程中,由于监管频率不高、监管行为滞后,不能及时对医疗机构不合理的行为进行约束和处罚；最后,受河南省医疗环境的影响,由于医疗资源比较匮乏并且分布不均,优秀的医疗机构在面对大量新农合患者的就医请求和政策的限制方面就很矛盾,虽然政策鼓励新农合患者尽量在所属地县区就医,但是要真正实现新农合患者的分流,最根本的路径还是切实改善基层卫生机构的就医环境和提供其治疗技术和水平。基于以上问题,本文提出以下建议：首先,要兼顾新农合患者的个人经济情况和医疗行业的发展,其次要大力发展基层卫生医疗机构,提高基层医疗机构的整体水平,加强对新农合患者日常保健理念的宣传,提倡防患于未然,为基层卫生机构分派例行保健任务,真正将就诊人数降低,实现病人分流。
[Abstract]:Henan's agricultural population accounts for more than 70 percent of the province's population. Since the introduction of the new rural cooperative medical system in 2003, 98.27 percent of the people in Henan Province have participated in this guarantee. The New Rural Cooperative Medical Scheme (NCMS) has provided hundreds of thousands of NCMS patients with billions of NCMS reimbursement compensation in the past ten years. However, at the same time, the rational use of the New Rural Cooperative Medical Insurance Fund (NCMS) has been highlighted. The compensation amount per capita is higher and higher, and the risk of overdraft of the new rural cooperative medical insurance fund is increasing. In order to prevent the overdraft of the new rural cooperative medical security fund and improve the efficiency of the fund, the Department of Health of Henan Province, together with the Department of Finance of Henan Province and other relevant units, launched the new rural cooperative medical care cost control reform policy in June 2012. The aim is to reduce the amount of compensation per person for reimbursement to each participating designated medical institution by prepaid, graded and quantitative amounts, while the number of visits remains unchanged or even increases. At the same time, limit the proportion of medication and treatment outside the reimbursement list of new rural medical security, to avoid excessive self-expense of NCMS patients. In this paper, two comprehensive public hospitals R and Z in Henan Province were selected as the research objects, and the medical data of the two hospitals from 2011 to 2013 and the evaluation data from the Agricultural and Health Department of the Department of Health of Henan Province were collected and collated. By comparing the volume of business and various related parameters before and after the implementation of the fee control policy between the two hospitals, this paper analyzes and discusses the effect of the implementation of the fee control policy, especially the existing problems and the causes of these problems. On this basis, the further improvement of the cost control policy and its implementation recommendations are put forward. Through the analysis, it is found that the cost control policy has really played a due role in the process of being implemented for half a year. The cost growth rate of NCMS patients has slowed down, and the proportion of drug expenses to the total cost has obviously decreased. Better to achieve the expected goal of the Department of Health in Henan Province. However, in the following year, the cost of NCMS patients increased significantly. The causes of these problems. Firstly, the contradiction in the public hospital system leads to the indifference of the public welfare and the enhancement of the profit driven by the public hospital. Secondly, in the process of implementing the policy, because of the low frequency of supervision and the lag of supervision, the unreasonable behavior of medical institutions can not be restrained and punished in time. Finally, under the influence of the medical environment in Henan Province, due to the relatively scarce medical resources and uneven distribution of medical resources, excellent medical institutions are in contradiction in the face of a large number of new rural cooperative patients' requests for medical treatment and restrictions on medical policies. Although the policy encourages NCMS patients to seek medical treatment as far as possible in their respective counties and districts, the most fundamental way to realize the shunt of NCMS patients is to effectively improve the access environment of primary health institutions and provide their treatment technology and level. Based on the above problems, this paper puts forward the following suggestions: first, to take into account the personal economic situation of NCMS patients and the development of the medical industry; secondly, to vigorously develop primary health care institutions to improve the overall level of primary medical institutions. We should strengthen the propaganda of the concept of daily health care for the new rural cooperative patients, advocate prevention, assign routine health care tasks to the basic health institutions, and truly reduce the number of patients and realize the diversion of patients.
【学位授予单位】：郑州大学
【学位级别】：硕士
【学位授予年份】：2014
【分类号】：R197.1;F842.684;F323.89

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