山东省新型农村合作医疗补偿机制研究

【作者】 王燕；

【导师】 孟庆跃；

【作者基本信息】 山东大学 ， 社会医学与卫生事业管理， 2007， 博士

【摘要】 背景和目的随着我国社会经济的发展，“三农问题”逐渐突出，为了缓解农民因病致贫、因病返贫，我国政府提出建立新型农村合作医疗制度。自2003年开展新型农村合作医疗试点工作以来，新型农村合作医疗制度建设取得快速发展。完善补偿机制，提高新型农村合作医疗基金使用效率是新型农村合作医疗制度实施中迫切需要解决的问题。国家卫生部也要求各地完善试点方案，规范运作机制，形成2-3种比较成熟的试点模式。从工作实践的需要出发，亟需在新型农村合作医疗制度的框架内，进一步完善新型农村合作医疗补偿机制的理论和技术，促进新型农村合作医疗可持续发展。本研究从分析各地的补偿方案及运行情况入手，从不同角度对新型农村合作医疗补偿机制进行研究，具体研究目的包括：1)系统总结补偿机制设计的相关理论和方法；2)分析管理人员的决策行为对新农合补偿机制的影响，了解农民的健康需求和对新农合补偿的意向建议：3)评价山东省不同经济水平地区的补偿类型及其运行效果，比较不同补偿类型和补偿规定对补偿受益的影响；4)探讨新型农村合作医疗补偿机制设计的补偿要素及其测算方法，分析各补偿要素之间的关系和影响新农合补偿受益的因素：5)拟定山东省不同经济水平地区补偿方案的指导性框架，提出完善新型农村合作医疗补偿机制的策略和建议。资料来源和方法本研究资料来源有两部分，即现有资料和调查资料。现有资料包括：各县(市、区)新型农村合作医疗试点工作方案、管理办法及有关文件、山东省2003-2006年新型农村合作医疗试点县(市、区)工作年报统计表、山东省2005年卫生统计信息年报。调查资料包括：试点县(市、区)补偿方案及补偿情况调查、部分市和试点县(市、区)政府领导、卫生行政部门和合作医疗经办机构管理人员问卷调查及非正式个人访谈、家庭入户调查、典型样本县2005年参合农民就诊和报销数据库备份资料。本研究将山东省至2006年运行满一个年度周期的46个县(市、区)全部作为研究对象。依据各县(市、区)补偿方案选取有典型意义的案例进行剖析。对118名市、县两级合作医疗管理人员、试点县政府分管领导、卫生局长、合管办主任进行问卷调查。家庭入户抽样调查分别在山东省经济水平高、中、低三类地区选定章丘、昌乐、东阿为样本县，三样本县内按经济水平和地理环境等因素选定三个乡镇，每乡镇随机选择三个村，每村随机抽取120户家庭，共调查3340户家庭。采用多种质量控制方法，保证调查数据质量。对定量资料进行描述性统计分析和非条件Logistic回归多因素统计分析方法，分析软件采用SPSS11.5。主要发现山东省开展试点4年来，试点地区农民参合水平总体较高，以县为单位平均达到88.6％。进行入户调查的三县(市)总体参合率达到91.3％。三县(市)因病致贫的比例分别为61％、60.9％和24.6％。农村家庭的医疗保障形式以新型农村合作医疗为主，只有一少部分购买商业医疗保险。农村应住院未住院的患者中，因经济困难导致的占60％以上。村卫生室是农村患者一般常见病的就医首选，相当一部分患者就诊后选择其他机构买药。样本县慢病患病率较高，且慢病患者自我健康评价以一般和差居多。大多数农民对新型农村合作医疗持满意态度，但对新农合的知晓水平较低。半数农民认为新型农村合作医疗应重点补偿花费数额较大、经济负担较重的大病，36.89％的人认为应重点补偿常见病多发病的门诊费用和一般住院费用。提高补偿比例是农民最强烈希望的改进措施，其次是改进报销程序。在新型农村合作医疗管理人员中，76％的调查对象认为合作医疗最应该解决的问题是大病风险，参合率和基金风险是影响管理人员决策的主要因素，管理人员的认知与决策之间存在矛盾。山东省46个县(市、区)所采取的补偿类型共有四种类型，即家庭帐户+住院统筹，家庭帐户+门诊统筹+住院统筹，门诊统筹+住院统筹，住院统筹，各县(市、区)在补偿类型的选择上有较强的区域相同性。有9个县(市、区)进行门诊慢性病补偿，有9个县(市、区)对住院分娩进行定额补偿。各县(市、区)的补偿方案中对起付线、封顶线、医药费用分段及不同费用段的补偿比例的规定有较大差别，缺少统一的确定标准，补偿水平不尽一致。不同补偿类型地区受益率有显著差异，实行门诊统筹+住院统筹的地区受益率最高。46个县(市、区)2005年基金结余率为22.73％，各县(市、区)基金结余差别较大，最高达69.34％，最低则出现负值，实行家庭帐户+住院统筹地区的家庭帐户基金沉淀较高。乡镇住院实际补偿比与方案规定补偿比例接近，县及县以上医疗机构实际补偿比与方案规定的补偿比差距较大。使用不同的新农合用药目录及住院起付线是导致实际补偿比与方案规定补偿比差距较大的主要原因之一。各试点县(市、区)2006年提高了筹资水平，均对补偿方案进行了调整。调整的主要做法包括：一是变更补偿类型，二是降低或取消住院起付线，三是调整费用分段，提高门诊和住院补偿比例，门诊补偿比例提高5-10％，住院补偿比例提高10-20％，四是增加慢性病统筹补偿、住院分娩等补偿项目，五是调整新农合用药目录。补偿方案的调整对各地新农合门诊和住院服务利用、补偿受益和基金收支产生了一定影响。与2005年相比，各地门诊和住院补偿受益面均有所扩大，补偿比提高，但低于筹资水平的增长幅度，主要与医疗费用上涨有关。根据调查月份的基金使用进度对新方案运行自然年度的基金收支情况进行预测，预计总体基金结余率为25.97％。对9个分别在补偿类型、住院起付线、补偿比例、慢性病补偿方面进行单项调整的县(市、区)进行调整前后的比较分析，取消门诊家庭账户实行门诊统筹使门诊补偿受益率提高，且减少乡镇住院，降低或取消住院起付线，增加了住院补偿受益，设置起付线导致住院补偿受益减少，而门诊受益人次增加。提高门诊和住院补偿比例使门诊和乡镇住院补偿受益率提高，而对县及县以上住院影响不大，说明针对重病的住院服务缺少弹性。以山东省不同经济水平地区的代表县(市)资料为基础，进行补偿方案的模拟测算，提出设计补偿方案的技术程序和步骤，以及需把握的技术要点。利用现有资料，采用增长系数法、患病率替代法预测卫生服务利用及费用。提出住院补偿应向就医经济风险临界线的医疗费用段倾斜。分析影响补偿受益的因素，对补偿受益率影响较大的因素依次为门诊补偿受益率、补偿类型、住院补偿比，对补偿比影响较大的因素依次为住院补偿比、次均住院费用、补偿类型、可补偿比例。利用住院费用频数分布表和测算得出的补偿比，观察住院起付线、封顶线和补偿比之间的关系。调整住院补偿起付线和封顶线都可导致补偿比变化，而调整封顶线对补偿比的影响大于调整起付线的作用，封顶线每提高5000元，补偿比降低0.5％-1％。讨论和政策建议本研究的核心是探讨合理利用现有资料进行新型农村合作医疗补偿方案设计的简便易行、可操作性强、便于基层人员掌握的方法。虽然没有采用相对复杂而更精确的数学模型，但是在测算过程中遵循了保险精算的基本原理，并在医疗费用预测、确定补偿起付线、封顶线、引入可补偿比例测算补偿比等方面有一定创新。同时对补偿方案进行多角度、多侧面的分析，有利于帮助决策者深入地把握新型农村合作医疗的内在规律，对补偿机制进行系统的理论总结也使研究的指导性更具有普遍意义。完善新型农村合作医疗补偿机制的主要建议包括：按照门诊和住院补偿支出各占基金总额40％和60％的比例分割基金；建议除东部沿海经济发达地区的部分市辖区实行单纯住院统筹外，其他地方均应将门诊医药费用纳入补偿范围；实行住院统筹和家庭帐户+住院统筹的地区都应附加门诊慢性病补偿；慢性病补偿和孕产妇保健补偿应分别与农村社区卫生服务中的慢性病管理和孕产妇系统化管理相结合，提高管理率；门诊补偿不设起付线；门诊补偿封顶线参照上年乡村卫生机构次均门诊费用的1-2倍或慢性病人的年平均医药费按住院补偿比例测算的补偿额设置；门诊补偿比例不应低于20％；乡镇住院补偿起付线参照当地乡镇卫生院门诊次均输液费用的2-3倍设定；县级住院补偿起付线参照当地县级医疗机构平均床日费用的2-3倍设定；县以上住院补偿起付线参照县以上医疗机构平均床日费用的2-3倍设定；住院补偿封顶线参照当地农民人均纯收入的3倍设定，且应覆盖90％以上的住院患者；在测算平均补偿比的基础上，以就医风险临界线费用段为高比例补偿费用段，向下递减或向上递增确定补偿比例。本研究由于时间原因目前只能局限于方法学研究，缺少实践的检验，这些将在后续的研究中继续加以完善。同时，本研究提出的方法受资料完整性制约较大，在某些地区可能不适用；对补偿设计的一些细节问题，如药物目录等也只是进行了原则性探讨，尚未做进一步的操作性研究。更多还原

【Abstract】 Background and ObjectWith the social and economic development in China, more and more attention is paid to rural area. To solve the problem that some families become and return into poverty because of disease, the Chinese government decided to establish the New Type of Rural Cooperative Medical System(CMS). Since 2003 CMS has been carried forwards rapidly. Perfecting the reimbursement mechanisms and improving efficiency of CMS is necessary. Ministry of Health asked to select 2 or 3 model of reimbursement system used for reference in every province. From the aim of practice,it is urged to produce a theories and techniques of CMS reimbursement actuary for the sustainable development of CMS.The study analyzes the situation and the package of CMS reimbursement in Shandong Province and give the proposal of design of reimbursement system of different area. The specific purpose of the study including, 1) Sum the theory and methodology of reimbursement mechanism design. 2) Analysis the the needs and the willings of the farmers and the behavior of the policy maker in the procedure of design of reimbursement system. 3) Compare the results of different reimbursement system in different economic area. 4) Analysis the factor which affect the CMS benefits, explore the relationships of the factors. 5) Produce the guiding framework of reimbursement system for different areas of Shandong Province, give the proposal of strategies for perfects mechanism of CMS.Data and methodsThe sources of information include two parts, the existing information and survey data. The existing information include, the document, statistics data of medical cost and reimbursement provided by the county CMS office, statistics data from regular reports provided by Health Department of Shandong Province. Survey data include pilot counties survey, interviews of local manager of different level CMS office, family households survey, the record of cost and reimbursement database backup material in 2005 of samples county .In the study, the record of 46 CMS pilot county are collected, 118 local manager were interviewed, Zhangqiu, Changle and Donga, three county are selected as samples county for family households survey, including 3340 households. Quality control method were done to guaranteed the data quality. The data were analysis by software SPSS11.5 and Microsoft Excel 2003.The main findingsThe percentage for the farmer participating the CMS was relatively higher compared with the average level of the whole country. The number was 88. 6% in Shandong Province in 2006, and was 91.3% in the three sample counties. The percentage of poverty caused by disease is above 60%. CMS is the main medical insurance system among the rural families .The percentage of the patient who should be hospitalized but not because of financial difficulties was more than 60%. The village clinic was the main choice for common disease. The most important factor be thought about when making the choice of health institution is convenience and technical level. A lot of patient chooses to buy drug in pharmacy. The rate of chronic diseases is relatively high. Most of patients of chronic diseases were not satisfied towards their health status. Most farmers were satisfied with the CMS. But the knowledge of the CMS was very poor. Half of farmers think the CMS should focus on the serious disease which would bring huge financial burden to the family. 36.89% of the interviewee think both of the cost of outpatient and inpatient should be covered and a few people suggest the cost of preventive service be covered. Increasing the co-payment is the strongest hope of the farmers. Among the local managers, 76% of the interviewees think that CMS should contribute to solving the serious disease and anti the disease risks. But in practice, the number of the participation and financial is the main factor that affects the decision-making. There is conflict between the thought and practice during the policy-making.There were four kind of model of reimburse system among the 46 counties, which is the model of medical saving account and planning inpatient cost as whole, the model of medical saving accounts and planning both inpatient cost and outpatient cost as whole, the model of planning inpatient cost and outpatient cost as whole, the model of planning only inpatient cost as whole. Chronic disease was covered in 9 counties. The cost of delivery was covered in 9 counties. The package, deductible, co-payment rate and ceiling are very different. The rate of benefits is different because of reimburse model. The rate of benefits in the area of planning inpatient cost and outpatient cost as whole is most high. The fund balances rate is 22.73% in 2005. The highest rate of the fund balances was 69. 34%. There is deficit in serval counties. The remainder rate is more high in the area of model of medical saving account. The actual co-payment rate in township hospital is higher than hospital of both county level and above. The number of the item of medicine covered by CMS payment and the deductible is the main reason for the difference between actual and name co-payment rate.In 2006, the reimbursement system was adjusted because of increased finacial budget from government. There is four types of the adjustment, which including changing model, reducing or cancel the deductible, improving the co-payment, covering the chronic disease. Compared with 2005, both benefits and co-payment level were increased. But the extent of increase of reimbursement is not fit for the increased financial because of the rising medical cost in all level of hospital. The balance of the fund was forecasted and the remained rate is 25.97%. The case study of nine counties was done. It is funded that canceling the medical saving account can improving the benefit and decrease the hospitalization. Reducing or cancel the deductible can bring the increase of the hospitalization. Improving the co-payment can bring the benefit of the outpatient and hospitalization in township hospital, and there is no obvious changement in hospitalization in the county level hospital and above. It is expressed that the service for serious disease lacks elasticity.Based on material of sample county in Shandong province, the model of the reimbursement of different area is designed. The method and step is introduced in the study. The key step is the forecast of the cost of the medical. The ratio of increasing of medical cost and the morbidity were used. The factor which affects the benefit and co-payment is analysised. The main factor is reimbursement model, copayment, the cost of inpatient and the ratio of medical cost covered. Both the adjustment of deductible and ceiling can change the benefit, but the affection of the ceiling is more obvious. As the ceiling be improved by 5000 Yuan, the co-payment rate will reduced by 0.5%-1%.Discussion and policy suggestionThe study is aimed to find the method that is easily be grasped and operated. During the process, though there is no complex mathematics model it is guided by insurance actuarial theory. Some new point was produced for the forecast of medical cost and the principle of the ceiling and so on. At the same time the reimbursement mechanism was analyzed from several direct and it is useful for help the policy-maker to master the rules of CMS.The main suggestion of perfecting the mechanism of CMS include the division the pool into out-patient part and in-patient part according to 40% and 60% respectively. The model of planning inpatient cost and outpatient cost as whole is suggested excepted the developed area. In the area where there is no planning the outpatient cost as whole chronic diseases shouled be covered. Both the chronic disease and pregnant women health service should be linked with the disease management to improve the utilization of the service. It is suggested no deductible of outpatient cost. The ceiling of outpatient payment is decided according the 1-2 times of average cost of outpatient in township hospital and village clinic. The ratio of outpatient co-payment should not lower than 20%. The deductible of co-payment of inpatient of township hospital is decided according to 2-3 times of outpatient infusion cost of township hospital. The deductible of co-payment in hospital of county level and above is decided according to 2-3 times of the cost per day in the same level hospital. The ceiling of the reimbursement is decided according to three times of the average income of local farmers, and more than 90% of patients should be covered. This study is limited to methodology because of the reason of time and the lack of proof in practice, which will be continued in the following study. Meanwhile, the proposed method is constrained by the data integrity, and in some areas it may not be suitable. Some detail problems included in the reimbursement system, for example there is only principle suggestion on drug item and lack of the further feasibility and manipulated method.更多还原