【作者】 龚勋；

【导师】 罗五金；

【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】 研究目的本篇论文是基于城镇居民基本医疗保险框架内的未成年人的缴费水平模型测算的一项理论探索和实证研究,是建立在不同年龄段和不同缴费水平的设计思路上的理论探索。本篇论文通过文献规范研究和实证研究,定性研究与定量研究相结合,研究国内外未成年人医疗保险缴费水平测算的相关资料,通过分析与总结我国各试点城市未成年人医疗保险缴费水平及模式的异同,以武汉市为研究对象,重点分析武汉市未成年人基本医疗消费需求特征及医疗保险基金补偿支出情况。同时,运用医疗保险学、保险精算学、社会学和经济学的有关筹资理论和方法,建立政府、医保部门、未成年人及其家庭等多方的医疗诉求及其优先次序关系；研究未成年人缴费水平所需的关键参数及其测算方法,构建未成年人适宜缴费水平的数学理论模型,为确定未成年人适宜缴费水平提供依据。研究方法(一)文献分析法查阅国内外医疗保险保费、筹资水平、补偿支出、保险因子、支付意愿以及我国各试点城市未成年人医疗保险缴费水平及模式的相关文献资料,运用内容分析方法对有关内容进行比较,进一步分析提炼可供本研究借鉴的理论和方法。(二)专家咨询法向医疗保险、卫生经济、卫生管理、医学社会学等领域的专家分别就末成年人年龄段划分、医疗保险补偿支出增长系数、政府、医保部门、未成年人家庭等多方诉求的优先次序等问题进行咨询,并通过专家座谈的方式对上述问题进行讨论。(三)专题小组讨论分别就政府和医保部门对未成年人缴费水平的测算依据、医疗诉求以及未成年人缴费水平的动态变化机制进行专题小组讨论,每个专题小组讨论由人力资源和劳动保障部门、财政部门、卫生行政部门、居民医保经办机构工作人员和高校教师等组成,共计28名。(四)知情人访谈通过医疗保险管理部门的知情人访谈,了解当前未成年人医疗保险的缴费水平的基本测算思路与方法。(五)现场调查法以武汉市为调查对象,按照社会经济发展、地理位置和医疗资源分行等特点,分别选取江汉区、青山区、洪山区和黄陂区作为本研究的现场调查地点。对未成年人参保情况、参保未成年人医疗保险基金补偿支出情况、未成年人缴费水平的测算依据和目标诉求情况、未成年人就医的医疗机构级别、基本医疗消费支出、居民医保的参保情况和家庭支付意愿等方面进行调查。对4个调查地点按分层随机抽样原则抽取500户的未成年人家庭。调查的具体内容包括未成年人就医的医疗机构级别、基本医疗消费支出、居民医保的参保情况和支付意愿等。(六)资料分析方法①使用描述性统计分析和多因素方差分析对未成年人的基本医疗消费需求特征进行分析；②使用四步模型法构造未成年人基本医疗消费支出的测算模型；③使用入户问卷调查,通过竞价法和直接法初步得出未成年人医疗保险家庭支付意愿；④使用排序法对政府、医保部门、未成年人家庭等多方目标诉求进行优先次序的比较；⑤构建居民医保未成年人适宜缴费水平的测算模型。研究结果(1)未成年人医疗保险的参保年龄分段为：0-1周岁,2-3周岁,4-6周岁,7-12周岁,13-18周岁。(2)人均未成年人医疗保险筹资额(S)的基本公式为：S’参保=(Go·Po,’·Ko·Eo·Co+Gi·Pi’·Ki·Ei·Ci)／(82%～96%)其中,Go表示年人均门诊就诊率,P’o表示次均门诊医药费用,Ko表示门诊补偿比例,Eo表示门诊保险因子,Co表示门诊增长系数,Gi表示年人均住院率,Pi’表示次均住院医药费,Ki表示住院补偿比例,Ei表示住院保险因子,Ci表示住院增长系数。(3)2008-2010年武汉市未成年人医疗保险实际补偿比为58.6%；若考虑武汉市7个中心城区高达93%的未成年人参保率,保险因子近似于1.0；若考虑不同级别医院的医疗费用差别,则一、二、三级医疗机构的保险因子分别近似为1.10、1.15和1.20。不同年龄段的未成年人在不同级别的医院就诊,其门诊和住院费用增长系数不一样；若选择医药费用比值法,则增长系数均值为0.538；若选择医药行业CPI为增长系数估计值,则为0.420；若选择综合比值法,则为0.745。(4)2008-2010年,武汉市未成年人的两周患病率、两周就诊率和年人均就诊率等差别不大(P>0.05),说明武汉市未成年人的疾病发生率变化不大,是一个相对稳定的疾病模型。0-1岁、2-3岁和4-6岁年龄段,男性和女性的两周患病率、两周就诊率和年人均就诊率的差别不大(P>0.05),7-12和13-18岁年龄段,男性和女性的两周患病率、两周就诊率和年人均就诊率间存在显著性差异(P＜0.01)(5)性别和年龄对医疗费用的支出有显著影响。不同年龄段的未成年人的医疗费用支出及其结构也存在着较大差异。其中,13-18岁年龄组的未成年人的医疗费用的差异显著。2-3岁和4-6岁年龄组的未成年人的医疗费用较高,住院利用率较高。(6)在社会经济等影响因素不变的情况下,武汉市未成年人医疗消费随着家庭收入的增加而增加,且家庭收入每增加1%,医疗消费支出将会增加0.6839%。若考虑物价增长和家庭恩格尔系数因素,由于基本医疗消费需求的刚性特征,家庭医疗支出已经成为家庭开支的重要组成部分。医疗费用的支出与未成年人的生理和心理发育阶段密切相关,也与不同年龄段所患疾病的类型及其分布密切相关。(7)未成年人家庭更愿意参照居民医保的缴费水平缴纳未成年人医疗保险。研究结论国内围绕着未成年人缴费水平测算的模型研究目前还属于初步探索阶段,未成年人的生理和心理发育的特点,及其疾病分布与结构特征,决定了其缴费水平测算的复杂性。家庭收入与支付意愿在一定程度上呈现正相关,但是由于医疗服务属于刚性需求,尤其是未成年人的医疗服务需求的刚性较成年人大,因此,政府和医疗保险管理部门在制定相关制度确定相关缴费标准、医疗费用补偿比等时必须慎重。国内部分学者提出保险因子的概念,认为在医疗保险制度中随着补偿比的提高,其医疗支出也将随之扩大,但是保险因子的测算仅仅局限于线性模型,系数估计的不准确使得我国实施医疗保险当中医疗费用的合理测算带来了相当大的困扰。按照不同年龄段测量的医疗费用支出特征和家庭支付意愿,0-1周岁未成年人缴费水平应在40元,2-3周岁和4-6周岁未成年人缴费水平应在50元,7-12周岁未成年人缴费水平应在40元,13-18周岁未成年人缴费水平应在30元。更多还原

【Abstract】 ObjectiveThis study is a theoretical exploration and empirical research of the model calculation of minors’payment level, based on the framework of basic medical insurance for urban residents. It is a beneficial exploration of design ideas based on different ages and different payment levels and standards. By doing literature and empirical research, combining qualitative research with quantitative research, studying materials about the medical insurance payment level of minors at home and abroad, the study analyzed and summarized the similarities and differences of the levels and models of Medicare payment in the pilot cities. Taken Wuhan city as an object of study, analyzes the consumer demand characteristics of the minors’basic medical insurance and expenses of material benefits fund in Wuhan. Using medical insurance theory, actuarial science theory, sociology and economics theories and methods related to financing,①to establish health care appeals and the multi-priority relationship which involves government, health care departments, minors and their families;②to study minors the key parameters and calculation method of minors’payment level, to build a mathematical model for an appropriate payment level of minors;③to demonstrate and amend the core parameters and constraints in building the theoretical model, providing the basis to determine an appropriate payment level. Research Methods (A) Document analysis Consult related literature on domestic and international medical insurance premiums, funding levels, compensation expenses, the insurance factors, willingness to pay, and the payment level and mode of minors in pilot cities, using content analysis method to compare the contents to figure out the theories and methods which can be utilized in this study.(B) Expert consultationInquire the experts in health insurance, health economics, health management, medical sociology about the priority among minors division by age, health insurance compensation expense growth factors, government, health care departments, juvenile and family parties and other issues. By expert panel, launch a discussion on these issues.(C) Focus group discussionsLaunch focus group discussions on government and related departments’calculation basis of minors’payment level, health care appeals and the dynamic mechanism of the level. Each group consisted of 4-6 members from human resources and labor security department, finance department, health administration, health care agencies.(D) Insider interviewBy interviewing medical insurance management department insiders, understand the current basic ideas and methods of calculation of minor health insurance payment level.(E) On-site surveyTake Wuhan as an object of study, in accordance with the social and economic development, geographical characteristics and distribution of medical resources, select Jianghan District, Qingshan District, Hongshan District, and Huangpi District as locations of the site survey. Investigate the insurance case of minors, material benefits fund expenditures, the residents health insurance agencies’calculation basis of minors payment level and target resorts, levels of medical institutions for minors’ medical treatment, basic medical care spending, the situation of the insured health care residents and willingness to pay and so on. About 500 families of minors are chosen in each location. The specific content of the survey, including levels of medical institutions for minors’ medical treatment, basic medical care spending, and residents insured situation and willingness to pay and so on. (Vi) Data analysis methods ①Use descriptive statistical analysis and multi-factor analysis of variance to analyze the characteristics of minors basic medical consumer demand;②Use the four-step model method to construct the calculation model of minors basic health consumer spending;③Using home questionnaires, initial bidding method and direct method, to calculate families’ willingness to pay;④Use the AHP to adjust the precedence order of the government, health care departments, juvenile families demands and target resorts;⑤Build a calculation model for an appropriate payment level of minors medical insurance.Results:(1) The age groups of insured minors were divided into:0-1 years old,2-3 years old,4-6 years old,7-12 years old,13-18 years old.(2) The basic formula for Per capita medical insurance financing is: S’=(Go·Po·Ko·Eo·Co+Gi·Pi·Ki·Ei·Ci)/(82%～96%)Go refers to per capita rate of out-patient treatment in one year; P o refers to per out-patient health care costs, Ko refers to the proportion of out-patient compensation, Eo refers to out-patient insurance factor, Co refers to out-patient increasing coefficient;Gi refers to the per capita rate of hospitalization treatment in one year; P; refers to per hospitalization costs; Ki refers to the proportion of hospitalization compensation; Ei refers to hospitalization insurance factor; Ci refers to hospitalization increasing coefficient.(3) From 2008 to 2010, the actual compensation rate for minors was 58.6%; if taking account of all the minors in 7 center districts in Wuhan, the insurance factor was approximated 1.0. If taking account of differences health costs in different level hospitals, the insurance factors of grade one, two, three medical are approximately 1.10,1.15 and 1.20 respectively. The minors of different ages hospitalized in different levels hospitals, the growth factors of outpatient and hospitalization costs were different; if adopting health care cost ratio method, the mean growth factor is 0.538; If taking pharmaceutical industry CPI as estimated growth coefficient ratio, it was 0.420; if adopting comprehensive ratio method, it was 0.745.(4) From 2008 to 2010, In Wuhan City, two weeks prevalence, two weeks treatment rate and per capita outpatient rate are not very different (P>0.05). It shows that the disease incidence in Wuhan is a relatively stable disease model. The two weeks prevalence, two weeks treatment rate and per capita outpatient rate changed much. The two weeks prevalence, two weeks treatment rate and per capita outpatient rate of 0-1,2-3 years old and 4-6 years age group, male and female are not very different (P> 0.05),while 7-12 years old and 13-18 years old age group, male and female are significantly different(P<0.01).(5) The relationship between health care costs with gender and age. The influences of gender and age on health care expenses are significant. The structure and the number of health care costs of different age groups are quite different. The health care costs of 13 to-18 age group were significantly different. The health care costs and hospitalization rate of 2-3 years and 4-6 years age group are higher. The health care costs of 13-18 years old group are quite different.(6) The influence of family income on health care costs. After a minor illness, if taking the development of social and economic factors as the same circumstances, the medical care cost increases as family income increases, and each 1% increase will cause health care cost increased by 0.6839 percent. If taking account of the price factor in growth and family Engel coefficient, due to the rigidity of the basic features of consumer demand, health care cost has become an important component of household expenditure. Health care cost is closely related with phases of the physiological and psychological development, and also the type of illness and its distribution.(7) the relationship between willingness to pay for health insurance and health care costs. Residents are more willing to pay health insurance for minors according to the level of the residents health insurance.ConclusionsThe study on measuring model of medical insurance financing is still in preliminary exploration stage. The minor’s physical and mental development characteristics and disease distribution and structure cause determine the complexity of financing measuring. The household income is positively related with willingness to pay, but due to demand for health care services are rigid, especially the demand for medical care services for minors is larger, so the government and the medical insurance management department must be careful to put forwards relevant rules, financing standard, medical expenses, compensation ratio. Some domestic scholars have proposed the concept of the insurance factor, and argued that medical expenditures will grow as the compensation ratio increases. But insurance factor was limited to the linear model, and the coefficient estimates are not accurate, which results in considerable problems for reasonable estimates of medical expenses. The research made a comprehensive comparison of domestic and foreign research results and the experience of one city, and set the corresponding demographic indicators (gender and age), household income, willingness to pay and disease type (including its distribution), and other factors affecting Empirical study of medical expenses, and combined the classification of medical insurance with the generalized linear model to reflect the role of the insurance factor, and so provided new ideas and methods to improve the management of minor medical insurance system.更多还原