【作者】 徐创洲；

【导师】 王征兵；

【作者基本信息】 西北农林科技大学 ， 农业与农村社会发展， 2011， 博士

【摘要】 农民“看病难、看病贵”现象一直是我国的一个突出的社会问题,政府帮助农民解决的措施是建立新型农村合作医疗制度(简称新农合),新农合自2003年试点之后在全国得以迅速推广,但是新农合减轻农民经济负担的效果并不明显,这是因为医药费用的过快上涨侵蚀了新农合的保险效果。不过新农合制度的建立,农民就医由直接付费变为第三者参与付费,又为控制医药费用的过快上涨提供了契机。新农合兼具医疗保险和医疗保障的双重属性,“合作”的理论基础是通过大数法则共同应对具有不确定性的医疗风险,而医疗保障又因为具有公共产品的特性会导致市场失灵,这时就需要政府管制。在医疗行业,供需双方信息不对称会引起供方诱导需求,还会导致逆向选择和道德损害现象,这些因素都会使本身就具有价格刚性特点的医药费用进一步升高,需要政府和参保人共同委托新农合管理机构作为代理人监督合作医疗的运行和控制医药费用的过快增长。由于医药费用的过快上涨既是一个世界性难题,又是一个历史性问题,所以既要借鉴国际做法,又要汲取历史经验。从世界上其他国家控制医药费用的经验来看,供方支付方式对医药费用控制影响最明显、效果最显著。主要的供方支付方式有按服务项目付费、按服务单元付费、按病种付费、按人头付费、按绩效付费以及总额预算制,这些支付方式在费用控制、预防效果、服务质量等方面各有特点,任何一种供方支付方式的优势要得到充分的发挥,都必须同时考虑医生报酬的结算方式。从我国城乡医疗保险控制医药费用的经验来看,传统农村合作医疗以其价格低廉的中草药和自制药、以预防为主的低水平保障、覆盖全国的三级卫生服务网以及低工资水平的赤脚医生有效降低了医药费用,这也与当时人民公社时期的政治体制有很大关系。城镇医疗保险在从公费医疗和劳保医疗向城镇职工医疗保险和城镇居民医疗保险转变的过程中,虽然改革总体上不成功,但是在改革过程中采取的一些控制医药费用的措施,如引入共付机制、调整服务价格、改革药品流通体制等,仍然值得新农合借鉴。新农合的内部条件和外部政策环境对其医药费用的控制也有重要影响,新农合政策的内部条件主要包括政策设计的优势以及缺陷、政策执行主体和客体的特点;政策的外部环境主要包括农村医疗市场的特点、医疗服务价格制定规则、药品政策、公共财政政策、医患关系以及政策的执行资源(财物、人力、信息、制度),这些都直接或间接的影响着新农合的医药费用。在新农合的方案设计中都有对医药费用的控制措施,本文通过分析H县住院医药费用的控制措施发现,按项目付费下的医药费用控制属于外力型控制,按病种付费下的医药费用控制属于内因型控制。在研究门诊医疗费用控制时,本文选取了32个县的门诊慢性病补偿方案,用医疗保险方案的三维框架分析了这些区县在覆盖人数、包含服务、共付比例方面的控制措施,发现不同区县的政策水平和补偿水平差异很大。新农合单病种付费方式是为了控制医药费用而产生的,本研究通过对陕西省H县781例住院患者的医药费用清单分析,研究了不同支付方式对例均总费用、药品费用、日均费用、日均药费以及医药费用构成的影响,发现支付方式改变了医生的用药方式:在按项目支付下使用目录外用药的比例是62%,而按病种付费时仅占4%,按项目付费的例均医药费用是按病种付费的2倍,按项目付费中药品费用占到了45%,而按病种付费的仅占16%,但是两种付费方式的日均费用却没有差别,这主要是因为单病种付费方式大大压缩了住院天数。通过以上研究,本文得出了六点主要结论:控制医药费用必须有度和前提、不存在完美的支付方式、医疗保障水平不是越高越好、控制医药费用的措施不能局限在保险制度之内、制定卫生政策基本框架的权利不应该下放到县级、单病种支付方式控制医药费用效果显著。本文认为新农合在控制医药费用方面应该充分发挥第三方支付者的作用,积极谨慎的进行医药费用支付方式改革,重点关注投资增加后新农合出现的新问题,逐步在全社会建立健康制度大循环的观念。同时,本文在研究控制医药费用的同时,发现和拓展了一些适用于“三农”问题研究乃至社会科学研究的四条规律,分别是:不合理现象惯性规律、政策力量传递理论、社会问题双向大循环理论以及涉农补贴“归零”现象。更多还原

【Abstract】 High expense and difficulties in medical care is an outstanding social problem in China, and the government try to resolve the problem by establish the New Rural Cooperative Medical System (NRCMS), which had covered nearly all Chinese rural areas since a pilot project launched in 2003. However, several studies have shown that the money paid by rural residents did not reduce because the escalating medical expenditures erode the effect of the NRCMS. The rural residents pay the medical expense out-of-pocket directly to hospital before the NRCMS introduced, but now the third-party payer appeared that made control the escalating medical expenditures more possible.The NRCMS has the characteristics of both medical insurance and medical security, and the law of large numbers is the theoretical foundation of“Cooperative”to cope with the uncertain medical care risk together. The medical security, as a public good, can lead market, so the government regulation is needed. The asymmetric information could cause provider induced demand, adverse selection and moral hazard in medical industry, all of these factors and the characteristic of price rigidity contribute to the escalating medical expenditures. So the government and insured people must authorize administrative organization the NRCMS supervise and control the escalating medical expenses.The escalating medical expense are not only a global problem, but also a historic issue, so we have to learn from the experiences and lessons of history and other countries. From the experiences of control the escalating medical expenditures in other countries, we can see the provider payment method is the most important measure which affects medical expense. The main provider payment methods are Fee-for-service, Diagnosis Related Group System( DRGs),Service unit, Capitation, Global budgets and Payment for performance. These methods have different effectiveness in cost control, disease prevention and the quality of medical service, and how the doctors get salary should be considered if any provider payment method wants to achieve its aim from macroscopic to microcosmic level.From the experiences of controlling medical expense under rural and urban medical insurance in China, We found the traditional RCMS has a good effect in cost control, that because it took on cheaper Chinese herbal medicine and self-made medicine, primary health care which put prevention first, rural three-tertiary medical and preventive health care network, low salaried barefoot doctor. There is another reason cannot be ignored that health care costs could transfer to the people’s commune because the political system in that period. The reform of urban medical insurance system is not so lucky.it was unsuccessful on the whole during the health care system transformation from free medical care and labor protection medicare to medical insurance for urban workers and basic medical insurance for urban residents. However, it still had some practices are worth learning from, such as introduced co-payment, adjusted the prices of health service, reformed the distribution system of drugs, ect.The policy environment of NRCMS has significant impact on controlling the medical expense. The interior conditions related with controlling medical expense include pros and cons of policy design, policy execute subjects and objects, policy resources. The external environment of policy are including characteristics of rural health service market, the producing mechanism of medical service price, drugs policy, public health financial policy and physician-patient relationship.There are some measures was designed in NRCMS benefit packages to control the medical expense. This study take H county, Shaanxi province as example, analyzed the control methods for inpatients, and found it is external control under fee-for-service payment method, but the DRGs is a kind of internal control. As for the outpatients, we selected 32 counties benefit packages of chronic diseases, analysis coverage of population, health service and costs, use three-dimensional of medical insurance as analytical framework and found that the policy level and compensation level are vary widely.The DRGs of NRCMS was introduced to control the medical expense. This study analyzed the detailed list of medical expenses of 781 inpatients in H county, researched the influence of different provider payment method to expense, including total medical expense, drugs cost, per day cost, per day drugs cost and expense components etc.we found that the reform of payment method changed the doctors’medical behavior, and there are 62% inpatients were prescribed the excluded directory drugs under fee-for-service, but 4% under DRGs, the per case expense under DRGs just half of the fee-for-service. The drugs fee account for 45% under fee-for-service, while 16% under DRGs. However, it is found that there is no difference between the DRGs and fee-for-service in the daily cost, the main reason is the DRGs reduced the days of hospital stay.We can draw six main conclusions by this study: controlling the medical expense should have premises; none of the provider payment method is perfect; it is not always the level of assurance higher is better; the measures of control the medical expense can not be limited within insurance scheme; the power of set up the health policy framework can not be authorize to county level; the DRGs of NRCMS had the desirable results to control the medical expense. This study also gives some policy proposal: the third-party payer should be play a positive role; the reform of provider payment method should be positive and careful; the government should pay more attention to the prominent issues after financial investment increased; the concept of greater health circulation should be encouraged in China.We also found and expanded four laws that can be employed to the issues of agriculture, rural residents and rural area, even social sciences. These are the law of inertia of unreasonable phenomenon, the law of policy strength transmission, the law of two-way circulation in social matters and the law of allowance disappears when related to rural residents in China.更多还原