基于UHC视角的农村居民大病保险补偿模式及实施效果分析

发布时间：2018-03-23 19:07

本文选题：大病　切入点：疾病经济风险　出处：《华中科技大学》2016年硕士论文

【摘要】：[目的]本研究着眼于我国农村大病患者,基于UHC视角,对其面临的疾病经济风险和影响因素以及新农合和大病保险抵御疾病经济风险的效果进行系统评价,对新农合大病保险制度提出完善建议,以提高其疾病经济风险抵御能力及公平性。[方法]本研究基于UHC视角,运用“结构—过程—结果”公共政策分析过程,构建大病保险评价指标体系,对政策及补偿效果进行评述,并评价补偿的公平性。通过文献查阅了解国内外大病医疗保障的相关制度体系与疾病经济风险评价等,运用文献研究法研究与整理。通过机构调查搜集样本地区2010-2014年新农合住院补偿数据库,通过入户问卷调查获取了472例大病患者就医行为及费用支出等情况,运用描述性统计、Logistic回归以及广义线性模型对大病患者保障水平现状及相关影响因素进行分析,运用灾难性卫生支出发生率、灾难性卫生支出相对差距等相关指标与反事实分析法测量新农合、大病保险制度的抗疾病经济风险作用。同时,通过灾难性卫生支出集中指数评价新农合以及大病保险制度补偿效果的公平性。通过关键人物访谈(新农合管理部门、民政部门、卫生行政部门领导和大病患者)了解农村大病医疗保障存在的问题与完善建议,运用框架分析方法对其进行结构分析。[结果](1)通过全国各省市大病保险政策梳理可知,各地区在制定大病保险政策的时候,都基于本地实际情况同时权衡基金承受能力,尽可能拓展大病保险覆盖范围和保障水平。在我国大病医保的实施过程中,既存在三种基本医疗保险之间的根本制度性差异,同时城乡居民大病医保制度在筹资标准、补偿参数设置以及经办方式等方面也不尽相同。(2)通过对新农合信息系统数据分析发现,大病患者住院天数长,2013-2014年平均住院天数为37天。大部分大病患者(90.0%)都前往三级医疗机构就诊。相对新农合住院患者,大病患者自付费用较高,经过新农合以及大病保险报销后,自付费用仍然高达24000元,且实际补偿比较低(约为50%),不可报销费用所占比例高(约为27%)。由患者入户调查数据库可知,大病患者两周就诊率为25.2%,其中44.4%的大病患者前往地市级及以上医疗机构就诊,门诊补偿较少,仅为20.6%。此外,大病患者直接非医疗费用与误工损失均较高(人均直接非医疗费用平均为3822元,人均误工损失为7279元)。有11.4%的大病患者有应就诊而未就诊的行为,有10.5%大病患者有应住院而未住院情况,有21%的大病患者有放弃治疗行为。大病患者总疾病经济负担沉重,经新农合和大病保险报销后仍有31.3%的大病患者家庭发生灾难性卫生支出。有72%大病的患者因病借债,人均借款金额高达46339元,52.5%的大病患者认为疾病经济负担很重。(3)教育水平、是否有医疗救助、基本医疗保险报销额度和大病保险报销额度是影响自付费用的主要因素。教育水平高,自付费用较低,没有医疗救助的患者自付费用是有医疗救助患者的1.02倍,基本医疗保险/大病医疗保险报销额度每上升1个单位,大病患者自付费用下降1个单位。(4)家庭收入、医疗费用、基本医保报销额度和大病保险报销额度是影响灾难性卫生支出的显著性因素。低中收入家庭比高收入家庭更容易发生灾难性卫生支出,其中,低收入家庭发生灾难性卫生支出的概率是高收入家庭的2.747倍,中收入家庭发生灾难性卫生支出的概率是高收入家庭的3.235倍。(5)经新农合补偿后,灾难性卫生支出发生率在原有基础上降低了41.3%,经大病保险补偿后,大病患者新农合补偿后大病保险补偿前降低12.2%,但是经过新农合和大病保险报销后灾难性卫生支出发生率仍高达31.3%;新农合和大病保险的补偿使灾难性卫生支出相对差距在原有基础上降低了38%和13%,但是补偿后大病患者灾难性卫生支出相对差距仍高达25%。(6)新农合补偿前灾难性卫生支出的集中指数-0.714;新农合补偿后大病保险补偿前灾难性卫生支出的集中指数-0.019;大病保险补偿后灾难性卫生支出的集中指数-0.286。集中指数均为负值,这表明灾难性卫生支出好发于贫困家庭,新农合补偿后,公平性显著改善,但是大病保险补偿后,灾难性卫生支出出现向贫困家庭转移的趋势。[结论](1)大病保险制度体系已经较为完备,但仍有完善空间。(2)大病保险筹资渠道较为单一,需要拓宽筹资渠道,建立稳定的筹资机制。为最大程度实现UHC,缓解大病患者疾病经济风险,需要动态调整优化大病医保补偿模式,科学确定起付线,确定合理补偿范围和补偿比例,保留或取消封顶线,与基本医保在补偿模式上有效契合,并精细测算,科学地确定大病医保的基金支出规模,为确定适宜的筹资标准提供参考依据。(3)大病保险实施刺激医疗卫生服务需求释放。大病保险实施改善大病患者经济可及性,刺激需求释放,有效促进UHC。同时,也应注意道德风险防范,管控不合理需求释放,科学控制医疗费用不合理增长。(4)大病保险缓解了疾病经济风险,但效果有限,且加剧了不公平。后期应该从人口、服务、直接费用三个维度完善大病保险补偿方案。扩大大病保险制度的覆盖面,调节政策公平性,合理界定合规费用,降低不可报销比,在提高大病患者住院水平的同时夯实门诊补偿水平。(5)促进基本医疗保险、大病保险和大病医疗救助有效衔接。大病保险应根据基本医疗保险保障水平科学制定保障参数,并动态调整。有效弥补基本医疗保险市外就诊报销比例偏低、报销目录窄、门诊保障水平低的问题。扩大对中低收入人群的保障,提高公平性。同时实行大病医疗救助对高自付费用患者和贫困人群进行“兜底”,从大病概念、保障对象、保障水平、结算时限等多方面与大病保险有效衔接。
[Abstract]:[Objective] this study focuses on the rural patients with serious illness in China, based on the perspective of UHC, to evaluate the effect of the disease economic risk and the influential factors of new rural cooperative medical insurance against disease economic risk, puts forward some suggestions on the new rural cooperative medical insurance system, to improve its ability to resist the disease economic risk and the fairness of the method. This study based on the perspective of UHC, using the "structure process outcome" of public policy analysis, construct the evaluation index system of serious illness insurance, review the policy and compensation effect, and to evaluate the fairness of compensation. Through literature review to understand the disease economic risk evaluation system and related system of domestic and foreign medical security, application research with the literature research method. Through the survey to collect 2010-2014 samples in hospital NCMS compensation database, through the questionnaire survey obtained 472 cases of patients with serious illness medical behavior and expense etc., by using descriptive statistics, Logistic regression and generalized linear model of factors present situation and related security level in patients with serious illness were analyzed, using the incidence of catastrophic health expenditure and related indicators of catastrophic health expenditure relative gap and counterfactual analysis method to measure the NCMS, the effect of anti economic risk the disease illness insurance system. At the same time, the fairness of the catastrophic health expenditure concentrated compensation effect evaluation index and NCMS illness insurance system. Through key informant interviews (new agricultural management department, civil affairs department, the administrative department of health and illness leading patients) understanding of rural catastrophic medical security problems and suggestions, use the framework of analysis the method is analyzed. The structure of the] (1) by various provinces and cities nationwide illness insurance policy combing the area of the When making a serious illness insurance policy, are based on the actual situation of the local fund balance and affordability, as far as possible to expand the coverage and security level of serious illness insurance. In the implementation process of China's serious illness insurance, the existing basic system between the three kinds of basic medical insurance and the difference between urban and rural residents illness insurance system in financing standard, the compensation parameter setting and handling methods are not the same. (2) based on the data of the new rural cooperative medical information system analysis found that patients with serious illness, hospitalization days long 2013-2014 years, the average hospital stay was 37 days. Most of the patients (90%) at the three level medical institutions. The relative hospital patients, patients with serious illness since pay higher fees, and after NCMS illness insurance reimbursement, payment is still as high as 24000 yuan, and the actual compensation is relatively low (about 50%), do not report the proportion of the cost of high pin (about 27%). The patients with household survey data show that patients with serious illness two week visiting rate was 25.2%, of which 44.4% of the patients with serious illness to the municipal level and above medical institutions, outpatient compensation is less, only 20.6%. in patients with serious illness, non medical costs and lost income losses were higher (per capita non medical costs an average of 3822 yuan, loss of 7279 yuan per capita). 11.4% of the patients with serious illness should be treatment without treatment of 10.5% patients with serious illness, hospitalization, 21% patients with serious illness to give up treatment in patients with serious illness behavior. The total economic burden of disease is heavy, and the NCMS illness insurance reimbursement is still 31.3% of the patients with serious illness, family catastrophic health expenditure. There are 72% serious illness patients due to debt per capita loan amount up to 46339 yuan, 52.5% of the patients with serious illness that disease economic burden is very heavy. (3) the level of education is. Any medical assistance, the basic medical insurance reimbursement and illness insurance reimbursement amount is the main factors influence expense. High levels of education, cost is low, no Medicaid patients cost is 1.02 times with medical assistance, the basic medical insurance / medical insurance reimbursement amount for every increase of 1 unit, ill patients cost decreased 1 units. (4) the family income, medical expenses, basic medical insurance reimbursement and illness insurance reimbursement amount is significant influencing factors of catastrophic health expenditure. Low income families in high-income families are more prone to catastrophic health expenditure, the probability of low income family disaster the health expenditure is 2.747 times as high income families, low-income families in the probability of catastrophic health expenditure is 3.235 times as high income families. (5) the compensation after the catastrophic health expenditure On the basis of the original incidence rate decreased by 41.3%, after a serious illness insurance compensation, patients with serious illness, serious illness insurance compensation compensation after a 12.2% reduction, but after the new rural cooperative medical insurance reimbursement after the occurrence of catastrophic health expenditure rate is still as high as 31.3%; new rural cooperative medical insurance compensation to catastrophic health expenditure relative gap on the basis of the original decreased by 38% and 13%, but the relative gap compensation after illness patients with catastrophic health expenditure is still as high as 25%. (6) compensation before the concentration index of catastrophic health expenditure -0.714 concentration index; serious illness insurance compensation compensation after the catastrophic health expenditure index -0.019; serious illness insurance compensation after the concentration index of catastrophic health expenditure -0.286. concentration was negative, suggesting that catastrophic health expenditure occurs in poor families, compensation, fairness significantly improved, but the serious illness insurance compensation After compensation, catastrophic health expenditure transfer to poor families. The trend of conclusion] (1) system of illness insurance system has been relatively complete, but there is still a perfect space. (2) a serious illness insurance financing channel is relatively single, to broaden the financing channels, establishing a stable financing mechanism. In order to achieve the greatest degree of UHC, alleviate the patients with serious illness the disease economic risk, dynamic adjustment and optimization of illness insurance compensation mode, scientifically determine the pay line, determine the reasonable scope of compensation and compensation ratio, retention or cancel the top line, basic medical insurance and effectively fit in the compensation mode, and fine calculation, scientifically determine the illness insurance fund expenditure scale, and provide the reference for the determination of appropriate financing standard. (3) a serious illness insurance stimulus medical service demand release. Patients with serious illness, serious illness insurance implementation to improve the economy and stimulate demand, effectively promote the release of UHC. at the same time, also Should pay attention to moral risk prevention, control unreasonable demand release, scientific control of medical expenses. (4) a serious illness insurance to ease the disease economic risk, but the effect is limited, and aggravate the unfair. The latter should from the population, the direct costs of the three dimensions of service, improve the serious illness insurance compensation. Expand insurance system the coverage of adjusting the policy of fairness, reasonable definition of compliance costs, reducing reimbursement ratio, increase in serious illness in hospitalized patients at the same level to reinforce the outpatient compensation level. (5) to promote the basic medical insurance, serious illness insurance and medical assistance effectively. Disease serious illness insurance should be formulated according to the basic medical insurance level science and security parameters, and dynamic adjustment. Effectively make up for the basic medical insurance of foreign medical reimbursement reimbursement list is low, narrow, low level of outpatient insurance problems. The expansion of low income guarantee, provided High fairness. At the same time the implementation of medical assistance to the high cost and poor people of patients reveal, from illness concept, security objects, security level, settlement time and other aspects and serious illness insurance effectively.

【学位授予单位】：华中科技大学
【学位级别】：硕士
【学位授予年份】：2016
【分类号】：R197.1;F842.684

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