精神分裂症患者门诊服务利用与特殊疾病统筹补偿方式分析

发布时间：2018-04-15 22:26

  本文选题：精神分裂症 + 门诊特殊疾病　； 参考：《华中科技大学》2012年硕士论文

【摘要】：研究目的 在了解精神分裂症门诊患者医疗卫生服务利用情况、医疗费用负担状况、医保政策补偿情况的基础上，讨论分析当前门诊医疗服务利用存在的问题以及医保补偿方式对患者医疗费用支出、就医行为和基金运行的影响，论证精神分裂症纳入门诊特殊疾病统筹的必要性，以及门诊特殊疾病统筹制度补偿方式的各项决策的合理性，继而提出更具有针对性的医疗保险补偿方式政策建议。 研究方法 通过回顾性数据调查法、典型问卷调查、知情人访谈等方式获取四个地区2010年城职和城居参保精神分裂症患者的门诊和住院医疗费用及补偿信息、门诊特殊疾病统筹政策实施效果等相关资料，在此基础上运用规范分析法、统计学分析法、专家论证法等方法对所收集的数据和信息进行分析。 研究结果 1．2010年武汉和杭州两地精神分裂症患者年人均门诊次数分别为7.4次和21.9次，杭州、武汉两地80%以上的门诊患者流向二级、三级医疗机构，杭州流向一级医疗机构门诊患者比重高于武汉流向一级医疗机构门诊患者比重。武汉和杭州两地患者次均费用分别为227.6元、268.9元，年人均费用分别为2043.2元、5893.3元，分别占到当地人均可支配收入的9.8%和19.6%。杭州门诊患者次均费用中药物费占95.9%，高于一般门诊病人费用的药占比（50.9%）。 2.武汉城职门诊患者年人均费用（2062.8元）高于城居门诊患者年人均费用（1847.7元），当地城职门诊患者实际补偿比（76.7%）高于城居门诊患者实际补偿比（44.2%），杭州城职门诊患者年人均费用（5905.8元）高于城居门诊患者年人均费用（4939.9元），当地城职实际补偿比（84.1%）高于城居实际补偿比（60.3%）；武汉城职、城居门诊患者可报销费用占总费用比重分别为78.7%和47.8%。武汉门诊患者自付费用影响因素有年龄、参保类型、就诊次数、就诊机构级别。 3.武汉、杭州、长沙、无锡的城职住院患者年人均自付费用分别为3475.1元、8781.1元、2796元、5183.7元，四地城居住院患者年人均自付费用分别为4875.1元、10809元、13760.4元、5726.2元，，数据经过校正后可发现门诊特殊疾病统筹政策保障的人群的住院费用较低。 4.2010年，武汉同时利用门诊和住院服务的参保精神分裂症患者人数为375人，占就诊患者总人数的7.1%，这类患者年人均总医疗费用13160.8元，年人均自付费用4245.1元。杭州同时利用门诊和住院服务的患者人数为344人，占就诊患者总人数的9.4%，这类患者年人均总医疗费用32760.6元，年人均自付医疗费用7656.1元。 5.模拟在杭州普通门诊统筹制度下就诊于基层医疗机构的精神分裂症门诊患者自付费用，城职患者年均自付费用1686.8元，城居患者年均自付费用2155.9元，占精神分裂症患者个人年均纯收入的39.6%和50.5%。 研究结论 1.普通门诊统筹制度保障能力有限，无法有效化解精神分裂症患者费用风险，患者自付费用负担过重，应优先纳入精神分裂症进入门诊特殊疾病统筹。 2.门诊特殊疾病统筹政策化解精神分裂症患者高额费用风险，并促使患者减少住院服务利用，提高统筹基金使用效率；但也存在患者门诊服务利用不足、药物利用安全隐患、基层医疗机构精神卫生服务提供能力欠缺、补偿方式的不合理、城职和城居制度公平性等问题，亟待改进。 3.在精神分裂症门诊补偿政策上，应取消起付线，同时依据当地精神卫生资源分布情况、结合精神分裂症患者人群特点合理设置补偿比例，引导患者合理就医，门诊特殊疾病统筹封顶线可与住院累计设置，逐步提高保障水平。对定点医疗机构采取按年度总额预付的支付方式，控制费用过快增长；在基层医疗服务机构精神卫生服务提供能力不足的情况下，门诊特殊疾病统筹定点医疗机构政策可适当放宽；基药目录可适当增加新型抗精神病药物，康复治疗项目应逐步纳入报销目录。此外，应出台针对精神分裂症患者参加门诊特殊疾病统筹的医疗救助政策。
[Abstract]:Purpose of study

On the basis of understanding the medical and health service utilization situation , medical expense burden and medical insurance policy compensation in outpatients with schizophrenia , this paper discusses the existing problems of medical service utilization in outpatient clinic and the effect of medical insurance compensation on medical expense expenditure , medical behavior and fund operation of the patient , demonstrates the necessity of integration of schizophrenia into outpatient special disease and the rationality of various decision - making in the compensation mode of outpatient special diseases , and puts forward the policy suggestion of more targeted medical insurance compensation mode .

Research Methods

Through a retrospective data survey method , a typical questionnaire survey , an intimate interview and so on , the data and information collected were analyzed by means of canonical analysis method , statistical analysis method , expert demonstration method and so on .

Results of the study

1 . In 2010 , the number of outpatient clinics in Wuhan and Hangzhou were 7.4 times and 21 . 9 times , respectively , and the proportion of outpatients with more than 80 % of outpatients in Hangzhou and Wuhan was higher than that in Wuhan .

2 . The annual per capita expenditure ( 2062.08 yuan ) of the outpatient clinic in Wuhan city was higher than the annual per capita expenditure ( 1847 . 7 yuan ) in the outpatient clinic of the city , and the actual compensation ratio ( 76.7 % ) was higher than the actual compensation ratio ( 44.2 % ) in the outpatient clinic of the city , and the annual per capita cost ( 5905 . 8 yuan ) of the outpatient clinic in Hangzhou city was higher than that of the city resident outpatient service ( 4939.9 yuan ) , and the actual compensation ratio ( 84.1 % ) in the local town was higher than the actual compensation ratio ( 60.3 % ) .
In Wuhan city , the proportion of the expenses of the outpatient department in the outpatient department of Wuhan was 78.7 % and 47.8 % , respectively . The factors influencing the self - payment of Wuhan outpatient department were the age , the type of reference , the number of visits and the level of the medical institution .

3 . In Wuhan , Hangzhou , Changsha and Wuxi , the annual per capita deductible expenses were RMB 3,75.1 yuan , 8781 . 1 yuan , 2796 yuan , 5183 . 7 yuan , respectively , and the annual per capita self - payment cost of the four urban residential houses was 4875.1 yuan , 10,809 yuan , 13760.4 yuan and 5726.2 yuan , respectively .

4 . In 2010 , the number of patients with schizophrenia treated with outpatient and inpatient services was 375 , accounting for 7.1 % of the total number of patients . The total annual per capita medical expense for this type of patient was CNY 13,160.8 , and the annual per capita self - payment expense was CNY 4,245.1 . In Hangzhou , the total number of patients with outpatient and inpatient services was 344 , accounting for 9.4 % of the total number of patients , and the total medical expense per capita in this type of patients was 32760.6 Yuan , and the annual per capita self - payment medical expense was RMB 766.1 Yuan .

5 . To simulate the self - payment of schizophrenia outpatients visiting the grass - roots medical institutions under the general outpatient service system of Hangzhou , the annual average self - payment of the city - office patients was RMB 1,86.8 yuan , and the annual average self - payment of the urban living patients was 2155.9 yuan , accounting for 39.6 % and 50.5 % of the individual annual income of the schizophrenic patients .

Conclusions of the study

1 . The limited capacity of the general outpatient planning system can not effectively resolve the cost risk of the schizophrenia patients , and the patient ' s self - payment expense is too heavy and should be given priority to the integration of schizophrenia into the outpatient special disease .

2 . To reduce the risk of high - level expenses in schizophrenic patients by the integrated policy of outpatient special diseases , and to promote the use of inpatient services and improve the efficiency of the use of integrated funds ;
However , there are some problems such as insufficient utilization of outpatient service , potential safety hazard of drug use , lack of ability of mental health service in grass - roots medical institutions , unreasonable compensation mode , fairness of city office and urban residence system , etc .

3 . In case of schizophrenia outpatient compensation policy , the pay - off line should be cancelled , according to the distribution of local mental health resources , the proportion of compensation should be reasonably set according to the characteristics of the population in the schizophrenia , so as to guide the patient to take a reasonable medical treatment , and the integrated sealing line of the outpatient special disease can be set up with the hospital accumulation gradually , so as to gradually improve the guarantee level . The fixed - point medical institution shall adopt the payment method paid in advance according to the total annual total , and the control cost is increased rapidly ;
Under the condition of insufficient capacity of the mental health service of the grass - roots medical service institutions , the policy of the outpatient special disease integrated fixed - point medical institution can be relaxed properly ;
The base - drug catalogue can properly add new antipsychotic drugs , and rehabilitation therapy projects should be gradually incorporated into the reimbursement directory . In addition , a medical assistance policy should be introduced for the treatment of schizophrenia patients to participate in outpatient special diseases .

【学位授予单位】：华中科技大学
【学位级别】：硕士
【学位授予年份】：2012
【分类号】：R197.32;R749.3

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