肺结核门诊费用纳入新型农村合作医疗补偿机制研究

发布时间：2018-06-14 21:10

本文选题：新农合 + 结防机构门诊费用　；参考：《山东大学》2012年硕士论文

【摘要】：结核病是由结核杆菌引起的慢性传染性疾病,其中以肺结核最为常见,据世界卫生组织报道,全球已有近1/3的人口感染过结核杆菌,每年新发结核病患者870万例,每年死于结核病的患者大约200万例。我国是全球22个结核病高负担国家之一,结核病患者数之多居世界第二；目前我国5亿人感染结核杆菌,600多万人患肺结核,其中200万患者具有传染性,每年死于此病的患者数达25万人之多,是各类传染病总死亡人数的2倍以上我国第四次全国结核病流行病学抽样调查结果显示80%的结核病患者在农村,3/4的患者为具有生产能力的青壮年。2004年开始我国推行了针对结核病患者的免费政策,但是免费政策只包括五种一线抗结核药物和部分检查项目(包括四次痰涂片和一次胸片检查),共计约250元。患者在实际治疗的过程中还需要接受肝功能等其他方面的检查和辅助治疗,治疗费用远远高于减免费用,绝大多数患者难以负担结核病的治疗费用,经济障碍直接影响了贫困家庭肺结核患者的就医。新型农村合作医疗制度(以下简称新农合)是我国农村居民的基本医疗保障制度,2003年试点以来运行情况良好。很多学者已经达成了利用医疗保障减轻结核病患者疾病经济负担的共识,各地也展开了这方面的尝试。目前关于结防门诊纳入新农合补偿方面的研究大多关注纳入后新农合对结核病防治管理工作的作用,而以何种方式纳入,纳入后的补偿政策以及纳入后在政策实施过程中的监管等问题研究较少。研究目的本研究分析目前项目县地区新农合资金运行情况以及新农合对结核病的补偿政策；分析在当前新农合补偿政策下,结核病供需双方的行为及患者的费用负担情况；研究结防门诊费用纳入新农合补偿、提高结防机构门诊费用的报销比例对新农合资金的影响；设计合理的结核病患者补偿服务包,明确结核病补偿的药品、检查种类,报销比例,补偿方式等。研究方法本研究根据目的性抽样原则、结防机构门诊费用是否在新农合报销范围内、目前新农合对结核病的报销方式,选取浙江省和四川省为项目省。根据成组设计两样本均数比较的样本量估计公式、当地结核病流行情况、患者代表性等因素决定每省选取4个项目县,每县调查患者50名。患者选取原则为2009年1月1日起至2009年12月31日为止在县结防机构登记且至现场调查前治愈或完成疗程的新发肺结核患者,患者应全部为加入新农合,年龄小于65岁的当地居民,非重症、未合并严重并发症或合并症且非耐药患者(严重并发症包括II型、严重肝、肾功能不全、严重心肺疾病、精神疾病、肿瘤等)。最终选取浙江省长兴县、安吉县、桐庐县、新昌县,四川省简阳市、雁江区、仁寿县、东坡区为项目县,共调查392名患者,同时收集这些患者在结防机构治疗的病案。本研究还访谈了项目县卫生局新农合办公室主任、结防机构负责人、结防机构医生,共24人。此外本研究还利用新农合机构调查表和结防机构调查表收集了项目县新农合基金收入支出数据、社会经济基本情况、结核病流行情况及结防机构基本情况,同时收集了项目县2005-2009年5年的新农合政策文件。本研究通过描述性分析、x2检验、秩和检验、多因素分析等方法分析研究项目县患者的医疗费用、疾病负担、供需双方行为、结防门诊费用的影响因素等。研究结果 1.项目县新农合补偿政策浙江省各项目县目前新农合补偿模式均为门诊统筹+住院统筹,门诊费用均按比例报销,住院费用均分段按比例报销,报销比例随医疗机构级别的变化而变化。四川省各项目县均实行家庭账户+住院统筹的报销方式,每人每年30元划入家庭门诊账户用于门诊医疗费用的报销,住院费用按比例报销。各县根据当地的新农合基金运行情况及财政状况制定了门诊特殊病种、二次补偿等进一步的补偿政策。新农合诊疗目录显示结核病诊疗常用检查(X线、血常规、尿常规、肝功、肾功等)以及一线抗结核药物均在报销范围内,而二线药、保肝药、免疫制剂等辅助用药则不在报销口录内。 2.项目县新农合基金运行情况调查表收集资料显示各项目县新农合实施以来,筹资标准、基金总额不断上升；起付线降低,报销比例和封顶线不断提高；基金运行平稳,没有出现风险。但是仍然存在门诊补偿支出比例过低,结余率过高的问题。 3.项目县新农合对结核病的补偿政策除国家推行的结核病免费政策外,浙江省安吉县、桐庐县,四川省简阳市、雁江区还对结防机构门诊费用实行了进一步的补偿政策,其余各项目县患者的结防机构门诊费用无法得到报销。安吉、长兴、简阳三地结核病患者在其他机构发生的门诊费用按照特殊病种政策进行补偿,其他项目县患者在其他机构发生的门诊费用以及所有项目县患者在其他机构发生的住院费用与其他疾病的报销政策相同。 4.患者结核病治疗费用及疾病经济负担浙江省纳入组患者医疗费用为4660元,占家庭总收入比例为43%,灾难性支出比例为28%；浙江省未纳入组患者医疗费用为5895元,占家庭总收入比例为29%,灾难性支出比例为44%；四川省纳入组患者医疗费用为4161元,占家庭总收入比例为55%,灾难性支出比例为49%；四川省未纳入组患者医疗费用为3879元,占家庭总收入比例为70%,灾难性支出比例为41%；医疗费用的报销在一定程度上可以降低患者的疾病经济负担,总费用报销比例在10%左右,报销后总医疗费用占年家庭收入的比例比报销前降低10%左右,报销后灾难性支出比报销前降低5%左右。 5.患者的就诊过程分析研究发现绝大多数患者都是通过其他机构转诊至结防机构的,仅有10%左右的患者是直接到结防机构就诊的。患者主要由县级和乡级医疗机构转诊至结防机构,没有人因为结防机构报销比例高而就诊,所有项目县患者平均就诊机构数均超过2个,长兴县就诊机构数甚至超过了3个。 6.提高新农合对结防机构门诊费用补偿比例对新农合基金的影响根据收集到的各省项目县的新发患者登记数、患者人均费用、新农合门诊补偿支出计算新农合结核病补偿支出占新农合门诊补偿支出的比例进行推算。通过分析发现随着新农合门诊补偿支出的不断增加,结核病补偿支出占新农合门诊补偿支出的比例不断降低。即使将结防门诊费用的报销比例提高到100%,用于结核病的补偿支出才不到五十万,占新农合门诊支出比例远远小于1%,可见提高结防机构门诊费用的报销比例对新农合基金影响较小。访谈对象对提高新农合对结核病报销比例意见各异,结防机构负责人和结防医生因直接与患者接触,了解患者的负担,都认为应该提高新农合对结防门诊费用的报销比例,他们也指出这需要相关部门的配合及政府的支持。新农合机构负责人表示不支持提高新农合对结核病的报销比例,因新农合基金有限,应向癌症、器官移植等大病倾斜。政策建议 1.加强肺结核相关知识的宣传力度,提高农村居民对肺结核症状、定点治疗单位、免费治疗政策的了解； 2.提高社会各界对肺结核病的重视程度,使大家认识到结核病是一项社会问题,关系到人民的生活、健康和社会发展,需要重视； 3.需要将结防门诊费用纳入新农合报销范围,以降低患者负担并提高肺结核病患者归口治疗管理率和依从性； 4.可以通过按比例报销的方式对肺结核患者进行补偿,需要扩充新农合药品报销目录,改善报销程序,方便群众报销；也可以通过将结核病作为特殊病种等其他方式对结核病患者进行补偿； 5.可以通过定额补助的方式对肺结核患者进行补偿,同时需要提高补助额度并取消起付线； 6.在改善新农合对肺结核患者补偿政策的同时需要加强监管,防治供方诱导需求和需方道德损害的发生。
[Abstract]:Tuberculosis is a chronic infectious disease caused by TB , among which tuberculosis is the most common , according to the World Health Organization . More than 1 / 3 of the world ' s population has been infected with TB , with 8.7 million new TB patients per year , with some 2 million people dying from tuberculosis each year . My country is one of the 22 high - burden countries in the world , with the largest number of tuberculosis patients in the world .
At present , 500 million people are infected with tuberculosis , more than 6 million people suffer from tuberculosis , of which 2 million have infectious diseases , and the number of patients dying each year is more than 250,000 people , and is more than twice the total number of total deaths of all kinds of infectious diseases

The fourth national tuberculosis epidemic survey in China shows that 80 % of tuberculosis patients in rural areas and 3 / 4 are in rural areas with productive capacity . Since 2004 , China has introduced free policy for tuberculosis patients , but the free policy only includes five first - line anti - tuberculosis drugs and partial inspection items ( including four sputum smear and one chest examination ) , which is far higher than the relief cost . Most of the patients have difficulty in the treatment of tuberculosis , and economic barriers directly affect the treatment of tuberculosis patients in poor families .

The new rural cooperative medical system ( hereinafter referred to as " Xingnong " ) is the basic medical security system of rural residents in our country , and the operation is good since the pilot project in 2003 . Many scholars have reached consensus on the use of medical security to reduce the economic burden of tuberculosis patients .

Purpose of study

This paper analyzes the operation of Xingnong combined funds in the current project and the compensation policy of Xingnong combined with tuberculosis ;
To analyze the behavior of tuberculosis supply and demand and the burden of patient ' s expenses under the current new agricultural co - compensation policy ;
To study the effect of the proportion of reimbursement of outpatient expenses on the new non - farm funds .
Design rational tuberculosis patient compensation service package , clear tuberculosis compensation medicine , check kind , reimbursement proportion , compensation mode and so on .

Research Methods

According to the principle of objective sampling , whether the cost of outpatient outpatient services is within the reimbursement scope of the new farming , the current new non - agricultural co - operation has selected 4 project counties in Zhejiang and Sichuan Province , and 50 patients in each county are selected according to the sample size estimation formula , the local tuberculosis epidemic situation and the representative of the patient . The patients should be all the local residents who have been cured or completed the treatment course before the site investigation . The patients should be enrolled in Xinong , and the patients with non - resistant patients ( serious complications including type II , severe liver , renal insufficiency , severe cardiopulmonary disease , mental illness , tumor , etc . ) . A total of 392 patients were selected from Changxing County , Anji County , Tonglu County , Xinchang County , Sichuan Jianyang City , Yanjiang District , Renshou County and Dongpo District .

Through descriptive analysis , x2 test , rank sum test and multi - factor analysis , this study analyzed the medical expenses , disease burden , supply and demand behavior of patients in the project county , and the influencing factors of outpatient costs .

Results of the study

1 . New Rural Cooperative Compensation Policy in Project County

In each county of Zhejiang Province , the current new farming and compensation mode is outpatient co - integration + hospitalization , and the outpatient expenses are reimbursed according to the proportion , and the reimbursement rate varies according to the change of the medical institution level . All counties in Sichuan Province have adopted a family account + hospitalization and integrated reimbursement method . Each county has established outpatient special disease type and secondary compensation according to the state of operation and financial situation of the local New Rural Cooperative Fund . The new agriculture combined diagnosis and treatment catalog shows that tuberculosis diagnosis and treatment common examination ( X - ray , blood routine , urine routine , liver function , kidney work , etc . ) and first - line anti - tuberculosis drugs are within the reimbursement range , while supplementary drugs such as second - line medicine , liver - protecting medicine and immune preparation are not in the reimbursement document .

2 . Operation of Xingnong Cooperation Fund in Project County

The data collected from the questionnaire shows that since the implementation of the new agriculture and agriculture in each project county , the fund - raising standards and the total fund have risen continuously ;
The decrease of the pay - down line , the proportion of reimbursement and the continuous improvement of the capping line ;
The fund runs smoothly and there is no risk . However , there is still a problem of low proportion of outpatient compensation expenditure and over - balance rate .

3 . Compensation policy for tuberculosis in project counties

In addition to the country ' s free policy of tuberculosis free of charge , further compensation policy has been applied to the outpatient costs of tuberculosis prevention institutions in Anji County , Tonglu County , Jianyang City and Yanjiang District of Zhejiang Province . The outpatient costs of patients in other projects are not reimbursable . The outpatient costs incurred by other institutions in Anji , Changxing and Jianyang are reimbursed according to the special case policies , and the outpatient costs incurred by patients in other projects in other institutions as well as the hospitalization expenses incurred by patients in other projects in other institutions are the same as those of other diseases .

4 . Cost of tuberculosis treatment for patients and economic burden of diseases

The medical cost of the patients in Zhejiang Province was 4660 yuan , accounting for 43 % of total household income and 28 % for disastrous expenditure ;
The medical cost of the non - enrolled patients in Zhejiang Province was 5895 yuan , accounting for 29 % of total household income and 44 % for disastrous expenditure ;
The medical cost of the patients in Sichuan province was 4161 yuan , accounting for 55 % of total household income and 49 % for disastrous expenditure ;
The medical expenses of the patients who were not included in the group were 3879 yuan , accounting for 70 % of total household income and 41 % for disastrous expenditure ;

Reimbursement of medical expenses can reduce the patient ' s disease economic burden to a certain extent , the proportion of total cost reimbursement is about 10 % , the proportion of total medical expenses after reimbursement is about 10 % lower than that before reimbursement , and the disastrous expenditure after reimbursement is about 5 % less than that before reimbursement .

5 . Analysis of patient ' s medical procedure

The study found that the majority of patients were transferred to the junction prevention facility through other institutions . Only about 10 % of the patients were directly to the junction defense mechanism . The patient was mainly transferred from county and township medical institutions to the junction prevention institution , and no one visited the junction because of the high reimbursement rate of the anti - defense mechanism . The average number of patients in all project counties was more than 2 , and the number of medical institutions in Changxing County was even more than 3 .

6 . To improve the effect of the proportion of the compensation ratio of the outpatient expenses of the new agricultural association on the New Rural Cooperative Fund

According to the number of new patient registration , the per capita cost of the patient and the compensation expenditure of Xingnong combined outpatient service , the proportion of the compensation expenditure of Xingnong combined outpatient service is calculated according to the number of new patients registered in each province project county . The proportion of the compensation expenditure for tuberculosis is less than 500,000 , which accounts for less than 1 % of the expenditure of the new agriculture combined outpatient service , even if the proportion of reimbursement of the outpatient expenses of the new agriculture combined outpatient service is increased to 100 % .

The participants also pointed out that the proportion of reimbursement of new non - outpatient expenses should be improved , and the proportion of reimbursement of new non - agricultural co - operation against tuberculosis should be improved . The head of the new agriculture association said it would not support the increase of the proportion of reimbursement for tuberculosis , and the new farm association fund should be inclined to cancer , organ transplantation and other major diseases .

policy recommendations

1 . Strengthen the propaganda of tuberculosis - related knowledge , improve the awareness of rural residents about the symptoms of pulmonary tuberculosis , fixed - point treatment units and free treatment policies ;

2 . To increase the level of attention paid to tuberculosis by all sectors of society and to recognize tuberculosis as a social problem , bearing in mind the people ' s lives , health and social development , requiring attention ;

3 . It is necessary to include the cost of junction anti - outpatient services in the reimbursement range of the new farmers , so as to reduce the burden of the patients and improve the management rate and compliance of the return treatment of patients with pulmonary tuberculosis ;

4 . The patients with pulmonary tuberculosis can be compensated according to the proportion of reimbursement , so as to expand the reimbursement directory of new agricultural chemicals , improve the reimbursement procedure and facilitate the reimbursement of the masses ;
tuberculosis patients can also be compensated by using tuberculosis as a special disease or the like ;

5 . The patients with pulmonary tuberculosis can be compensated in the form of fixed allowance , and the allowance limit should be increased and the pay - off line shall be cancelled ;

6 . In order to improve the compensation policy of the patients with pulmonary tuberculosis , it is necessary to strengthen the supervision and control the demand of the supplier and the occurrence of the moral damage of the demander .
【学位授予单位】：山东大学
【学位级别】：硕士
【学位授予年份】：2012
【分类号】：R521;R197.1

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