【作者】 陈埙吹；

【导师】 姚岚；

【作者基本信息】 华中科技大学 ， 社会医学与卫生事业管理， 2011， 博士

【摘要】 研究目的本研究旨在通过梳理医疗救助与基本医疗保险衔接相关理论,对当前医疗救助与基本医疗保险制度衔接的实证分析,探索两种制度在政策目标、方案设计、服务管理、部门协作机制等方面可行的优化衔接模型和策略,实现医疗救助与基本医疗保险制度之间的“无缝衔接”。研究方法本研究的资料来源包括文献资料、2007-2010年全国卫生统计年鉴和民政部统计数据的宏观数据、31个省(直辖市、自治区)医疗救助及“一站式”即时结算相关数据、典型地区的现场调查数据。研究方法包括文献分析法、典型案例法、专题小组访谈、定量分析以及系统分析法。主要研究结果1.医疗救助与基本医疗保险衔接的理论研究。本研究从医疗保障制度设计、公平理论、公共产品理论、健康权理论角度出发阐述了两者衔接的理论基础,并基于我国多层次医疗保障体系的基本原则,比较了两种制度的性质与特点。基本医疗保险的特点包括广泛性、对等性、互济性、筹资的适度性和保障的有限性。医疗救助制度的特点包括群体的特定性、资金渠道的单一性、救助水平的有限性、与基本医疗保险的协同性。两者的相同性体现在具有共同的政策目标、政府的主导作用、定点医疗服务机构、医疗服务内容、诊疗和用药目录以及费用补偿方法。两者的差异性表现为性质不同、覆盖人群和保障范围不同、保障程序不同、资金筹集渠道不同和管理体制不同。两者之间具有相对的独立性,在结构上构成了平行的关系；在组织和服务管理以及保障内容上,又具有动态关系。所以,两种制度衔接的必要性体现在五个方面,即保障和提高贫困人口的受益水平,需要依靠医疗救助与基本医疗保险制度两者的共同努力；两种制度的结合有利于加强对医疗机构的监管；管理层面的衔接有利于降低制度的管理成本；报销服务的衔接有利于方便困群众就医；消除制度分割和独立运行带来的影响。两者进行衔接的可行性包括政策保障和互补性。政策保障是指医药卫生体制改革意见及相关文件对两项制度衔接提出了要求。互补性包括政府责任与个人责任互补、保障对象上所有人群与贫困人群的互补、保障程序上规范性和灵活性互补、保障内容上统一性与特殊性互补、保障水平上普惠性与重点性互补。衔接的障碍包括三个方面,即部门职责划分造成制度间的割裂,制度之间的割裂影响了贫困人群医疗卫生服务的利用,低水平的基本医疗保险给医疗救助的衔接带来很大压力。2.本研究利用全国层面的数据从覆盖人群、基金的筹集与使用、制度衔接三个方面描述了医疗救助制度与基本医疗保险制度衔接的现状和发展趋势,发现存在的主要问题是资助参保参合率近年来虽大幅提高,但仍没有做到“应保尽保”；医疗救助筹资和补偿水平较低,与贫困人群基本医疗卫生需求存在较大差距；住院救助率仍低于一般人群水平,贫困人群的基本医疗卫生需求未得到充分释放；住院救助与门诊救助发展不均衡,需要进一步科学设计救助内容及资金支出构成。3.“一站式”即时结算衔接模式从信息系统角度划分,包括统一开发式、独立开发式和导录式。这三种模式在衔接方式、管理效率、信息共享上各有特点,实施后均提高了住院救助率和降低资金结余率,有利于提高医疗救助的可及性,同时降低管理成本、提高医疗救助工作效率。实施“一站式”即时结算要求民政部门具备四个方面条件,即具备更强的协调能力,建立稳定的经费筹集机制,通过各种方式加强对定点医疗机构的监管,信息系统在人员认证上不断更新完善。存在的主要问题包括救助对象住院率大幅增加,给救助资金安全性带来风险；即时结算受区域和定点医疗机构的限制,影响医疗救助可及性和公平性；基本医疗保险系统未实现统一,影响了医疗救助即时结算在省级层面的融合。4.本研究选择了福建省邵武市、吉林省吉林市、重庆市合川区作为典型地区,分析医疗救助与基本医疗保险衔接后产生的效果,比较不同衔接方案和模式的特点。衔接后的效果主要表现为住院救助率提高、资金结余率降低、救助对象保障水平提高、等待审批时间缩短。衔接模式的共同特点包括取消救助起付线、扩大病种范围、提高救助封顶线、开展多层次救助衔接内容和方式等。5.在全国层面和典型地区实证分析的基础上,本研究依据系统分析法提出医疗救助与基本医疗保险制度衔接的优化模型及策略。模型包括逻辑框架和结构框架。逻辑框架依据“系统目标-系统环境-系统要素”的逻辑链条建立。结构框架由四个方面构成,即政策衔接、组织管理、技术设计和服务管理。其中组织管理包括部门职责和协调机制两方面,技术设计包括四个衔接层次以及五个关键技术环节,服务管理包括人员管理、资金管理、监督控制、信息服务和结算服务五个部分。衔接的策略包括五个方面,即在国家层面成立医疗救助、新农合和城镇居民医保制度衔接的协调小组,是解决基层部门之间制度割裂的先决条件；做好贫困人群的参保参合工作,使救助对象能够享受一般人群的基本医疗保险；医疗救助应建立与我国经济水平同步增长的筹资机制；在合理测算医疗救助资金需求的基础上,科学调整医疗救助政策；探索特重大疾病救助,与基本医疗保险制度改革路径相契合。本研究的创新与不足之处1.本研究的创新之处在于利用系统分析法,按照“系统目标-系统环境-系统要素”的逻辑链条,将医疗救助与基本医疗保险制度衔接的理论分析、现实障碍、模式选择进行有机融合,实现了从理论到实践,以及从实践重回理论的过程,突破了以往研究单方面注重理论分析或实践研究的局限,在理论联系实际基础上提出了两类制度衔接的优化模型。2.本研究的不足之处是缺乏来自需方的疾病经济负担和满意度数据,待数据可得和时间条件可行情况下,可以作进一步分析,从疾病经济负担减轻和满意度角度评价制度衔接的效果。更多还原

【Abstract】 Study PurposeThis Study aims to, through screening the theories related to the link-up between medical assistance and basic medical insurance as well as empirical analysis of the current link-up between medical assistance and basic medical insurance system for urban and rural residents, explore feasible optimized link-up model and strategy for the two systems in such aspects as policy objectives, scheme design, service management and departmental collaboration mechanism, in order for realizing a "seamless link-up" between medical assistance system and basic medical insurance system.Study Methodology The data sources for this Study include literature materials,2007-2010 Chinese Health Statistics Yearbooks and macro-data collections from the statistical data of the Ministry of Civil Affairs of PRC as well as the filed surveys in typical regions. Study methodology includes literature analysis approach, typical case approach, special-topic group interview and quantitative analysis.Study Results1. This Study theoretically analyzed the natures and characteristics of basic medical insurance system and medical assistance system. The characteristics of basic medical insurance include universality, equality, reciprocity, financing adequacy and security limitation. The characteristics of medical assistance system include specifically of populations, singleness of fund channel, limitation of assistance level and cooperatives with basic medical insurance. The similarities of the two are embodied in: (1) Both aim at achieving the common policy goal of ensuring basic health care services for every one; (2) The government plays a dominating role in the process of system establishment and development; (3) Both have common designated medical service institutions; (4) The medical service contents are similar, and both focus on major diseases, aiming at solving the basic security issues of hospitalization, and giving consideration to outpatient services; (5) Both have the same catalogues of diagnosis and treatment and medicine use; (6) Both have the same method for expense compensation and subsidy. The differences between the two are manifested in different natures, different populations covered and security scopes, different security procedures, different fund-raising channels, different management systems. So there is relative independence between the two, and a parallel relation is constituted in structure; there is also a dynamic relation between the two in compensation time and mutual influence. The necessities, feasibility and barriers for the link-up between medical assistance system and basic medical insurance system. Necessities includes: (1) Effective link-up between the two systems is a necessary condition for ensuring poverty populations benefiting therefore. (2) The combination of the two systems facilitates hospitals is good for the supervision of medical institutions. (3) The link-up at management level facilitates reducing management costs of systems. (4) The link-up for reimbursement service facilitates realizing instant assistance. (5) To eliminate the bad effects of system operating independently. The feasibility for the link-up between the two includes policy security and complementation. Complementation include complementation between governmental responsibilities and personal responsibilities, complementation in security objects between all populations and poverty populations, complementation in security procedure between standard ability and flexibility, complementation in security content between unity and particularity, and complementation in security level between universal benefit and emphasis. The barriers for the link-up between medical assistance system and basic medical insurance system include three aspects, namely:the division of departmental duties causes the separation between systems, while the separation between systems influences the utilization of health care services by poverty populations, whereas low-level basic medical insurance for urban and rural residents brings about high pressure to the link-up of medical assistance.2. By use of macro-data, this Study describes the status quo and development trend of the link-up between medical assistance system and basic medical insurance system at nationwide level from three aspects, namely populations covered, raising and use of funds and system link-up, and finds the existing main problems as follows:(1) Financial aid-based insurance participation rate and participation rate of New Cooperative Medical System have been improved significantly in recent years, however, the requirement for "covering all required" still has not been met; (2) The level of compensation for urban and rural assistance objects is relatively low, which results in a greater gap from the needs of poverty populations; (3) Basic medical security system preliminarily established a fund-raising mechanism for steady growth, but the fund-raising level is still on the low side; (4) The development of inpatient assistance and outpatient assistance is unbalanced, so work should be done to further scientifically design the assistance contents and the composition of funds expenditures.3. The link-up modes of "one-stop" instant settlement are classified, from the perspective of information system, into three types:unified development type, independent development type and guiding record type. These three modes have their own characteristics in link-up manner, management efficiency and information sharing, and all of them improved the inpatient assistance rate and reduced the fund balance rate after the implementation thereof, therefore, they help increase the access to medical assistance, meanwhile reduce management costs and improve work efficiency of medical assistance. The reform conditions are those:(1) New link-up modes poses higher demands to the coordination capacity of the department of civil affairs; (2) The link-up modes of "one-stop" instant settlement need the establishment of a steady mechanism for fund raising; (3) The department of civil affairs need to strengthen regulation of designated medical institutions; (4)The information system need the constant improvement in personnel certification.The existing main challenges include:(1) Significant increase in the hospitalization rate of assistance objects brings about risks to the safety of assistance funds; (2) Instant settlement is limited by regions and designated medical institutions, hence influencing the access to and equity of medical assistance; (3) The unification of the systems of basic medical insurance for urban and rural residents has not yet been realized, which influences the integration of medical assistance instant settlement at provincial level.4. This Study takes into account the characteristics of system link-up and the modes of "one-stop" instant settlement, selected four typical regions from East, Central and West China, namely Shaowu City of Fujian Province, Jilin City of Jilin Province, Hechuan District of Chongqing City and Huzhu County of Qinghai Province, analyzed the effects generated after link-up of medical assistance with basic medical insurance for urban and rural residents, and compared the characteristics of different link-up schemes and modes. The effects after link-up are manifested mainly in increase in hospitalization assistance rate, decrease in fund balance rate, improvement in the security level of assistance objects and shortening of the time of waiting for examination for approval.5. On the basis of system analysis method, this Study put forward the optimized model for link-up between medical assistance system and basic medical insurance system for urban and rural residents. The model consists of logic frame and structure frame. The logic frame is built by the logic chain of "system target-system environmental-system elements". And the structure frame includes four aspects, namely policy link-up, organizational management, technical design and service management. Wherein, organizational management includes two aspects, namely departmental duties and coordination mechanism; technical design includes four link-up levels and five key technical links; service management includes five parts, i.e. personnel management, fund management, supervision and control, information service and settlement service. The link-up strategy includes five aspects, namely doing well the work for poverty populations’participation in insurance and New Cooperative Medical System, and enabling assistance objects to enjoy basic medical insurance of general populations; a fund raising mechanism for medical assistance should be established with growth in step with Chinese economy level; on the basis of reasonable estimation of needs for medical assistance funds, scientifically adjusting medical assistance policy; improving medical assistance system, and providing system security for advancing "one-stop" instant settlement.The Innovations of This PaperThe innovations of this paper are those it merged the theoretical analysis, realistic obstacles and mode selection of the link-up between medical assistance and basic medical insurance according to the logic chain of "system target-system environmental-system elements" of system analysis method, and realized the procedure from theory to practice and then from practice to theory, proposed the link-up optimized model of the two systems by combination of theory and practice.The Flaws of This PaperThe flaws of this paper are those it lacks the data of economic burden of sickness and degree of satisfaction. And the paper could further study on the effect of system link-up by available data and enough time.更多还原