【作者】 李力；

【导师】 李士雪；

【作者基本信息】 山东大学 ， 社会医学与卫生事业管理， 2013， 博士

【摘要】 研究背景中国是高血压大国,高血压平均患病率达到38.6%,发病人数已经超过2亿。高血压疾病在严重影响患者健康状况的同时,也给患者及其家庭带来了沉重的经济负担,由于高血压病是不能根治的疾病,患者往往需要接受终身治疗,因此高血压病情的变化和伴随疾病的进展会对医疗费用产生较大的影响。从高血压疾病经济负担的角度来看,基本医疗保险制度是降低个人、家庭和社会疾病经济风险最直接的手段,它是从经济角度来改善健康行为、提高健康干预、促进疾病转归的一种重要的制度安排和经济补偿措施,作为一项提高公共健康福利的基础性政策,其在提高医疗卫生服务可及性与可承受性,最大程度的降低疾病经济风险、发挥对社会资源的再次分配、促进和维护社会稳定和谐等方面具有不可替代的功用。但我们也要清楚的认识到,在我国以基本医疗保险为主体的医疗保险体系在补偿效果、补偿公平性方面还存在一定不足,这些问题需要在制度的建立和完善过程中得到不断的解决,这也是本研究的现实依据。研究目的通过现场调查了解高血压疾病人群在药品、门诊和住院治疗中的卫生服务利用情况、疾病费用情况、补偿情况等信息,利用疾病负担的常规指标来衡量高血压疾病对人群造成的经济风险。同时比较评价现行的基本医疗保险制度对人群低于疾病经济风险的补偿效果、补偿公平性及影响因素。在此基础上,结合医疗保障制度由数量增长向结构调整的改革趋势,提出提高基本医疗保险制度公平性的改进策略,以提高不同医保制度之间的横向公平性,提高城乡居民尤其是贫困人群对高血压疾病经济风险的抵御能力。资料来源定量资料主要来源于现场调查,本研究采取多阶段随机抽样的方法,根据地域分布和社会经济状况从山东省140个县区中随机抽取4个城市社区(烟台福山区、莱州莱城区、枣庄薛城区、德州德城区)和4个农村县区(威海乳山市、潍坊高密市、泰安宁阳县、潍坊寿光市)。每个城市区以随机整群抽样的方法抽取3个社区,每个农村县(市)以随机整群抽样的方法抽取3个乡镇,全省共确定12个社区和12个乡镇进行调查。每县区所抽中的社区和乡镇内的所有登记的高血压患者均为此次调查的调查对象(包括各街道和村的患者),全省共抽取9054名高血压患者。调查内容主要包括高血压患者及家庭的基本情况、疾病状况、高血压门诊、住院和药品利用情况等。研究方法1文献复习法用高血压、成本、负担、费用、价格、保险、公平性等主题词检索cnki、万方、维普、Pubmed、EBSCO等中英文文献数据库,了解高血压在中国的流行现状、疾病经济负担的研究方法、风险管理、健康贫困防治策略等内容,同时系统回顾里疾病经济负担、医疗保险公平性等方面的理论和实证研究,了解国内外对疾病经济负担、疾病经济风险度评价、宏观医保制度设计策略等方面的改革进展等。2数据分析方法(1)描述性分析。利用计算资料的均数、标准差、率和构成比、频数分布描述等方法对本次调查的社会人口学特征、疾病流行特征、行为生活方式等方面进行描述。(2)疾病负担分析。对影响高血压患者经济负担的单影响因素主要采用t检验、Kruskal-Wallis H检验、Mann-Whitney U检验；测量灾难性卫生支出的发生率,并利用灾难性卫生支出的平均差距和相对差距法估计其严重程度；收集的医疗保险补偿金额、家庭收入、门诊支出、住院支出等信息采用Probit模型、方差分析、卡方检验等统计方法进行多因素分析。(3)医疗保险补偿分析。用率、构成比等指标分析不同医疗保险在门诊、住院和高血压药品补偿方面的补偿水平和补偿比,同时采用泰尔指数法测量补偿公平性。(4)卫生服务利用分析。通过门诊率、住院率等指标进行描述,同时利用卫生服务利用标准化法、集中指数法(CI)对公平性进行实证研究,主要分析非经济收入因素对卫生服务利用的影响。研究结果1高血压负担高血压患者年高血压门诊支出为570.72元,年住院支出为7162.5元,住院负担尤其是农村家庭的负担程度要高于第四次卫生服务调查的平均水平。此外,高血压药品支出也相对较高,患者年支出金额平均为565.72元。2灾难性卫生支出城乡居民接受高血压门诊或住院治疗后,可以对一部分家庭造成家庭灾难性支出,发生灾难性卫生支出的概率约在3%-5%之间,从发生概率来看,门诊治疗发生比例最高,从危害程度来看,住院支出影响更大。从经济风险度评价来看,低收入家庭所承受经济风险较高。3医疗保险方面本次调查发现,新型农村合作医疗、城镇职工医保、城镇居民医保三大类基本医疗保险仍是调查人群的最主要的参保类型,非基本医疗保险也会对少部分患者家庭的医疗费用支出产生一定影响。多元回归统计结果也显示,无论是门诊方面还是住院方面,医疗保险均会对实际费用支出和卫生服务利用产生影响。从医保基金的使用情况来看,住院补偿是基本医疗保险补偿的重点,住院补偿金额约占各类医保支出总额的49.38%,其次是门诊补偿,占34.81%,药品补偿的比例占15.81%。4补偿效果医疗保险因素对高血压疾病的影响作用主要体现在卫生服务利用数量和疾病负担的改善。从卫生利用次数上来看,利用probit模型发现非疾病因素,尤其是医疗保险因素对疾病负担产生影响。从负担改善情况来看,各种类型医疗保险对门诊、住院和高血压药品支出方面的平均补偿水平为350.63元,占家庭收入的比重为2.16%。从社会经济角度进行分层比较,医疗保险因素对低费用支出情况的补偿效果较好,此外发现医疗保险的补偿金额占低收入家庭的比重远高于其他家庭类型。5公平性评价从基金使用内部情况看,门诊补偿公平性要好于住院补偿,但均存在高收入人群受益好于低收入人群的情况；不同医疗保险间也存在不公平现象,泰尔指数结果显示城镇职工医疗保险的受益程度最高。结论与建议从结果来看,高血压疾病会对患者家庭普遍造成一定的经济损失,部分家庭在门诊、住院和药品支出方面会显著增加家庭的经济风险,产生经济风险的原因既与疾病因素有关,也与其他社会经济因素有关。从医疗保险的角度来看,现行制度对特定家庭来说还是具有较大的影响作用,其经济风险的分担能力对提高卫生服务利用和降低经济负担的损失具有较为明显的作用。但研究结果也表明,这种风险分担能力在不同医疗保险制度间以及不同社会经济背景人群之间是存在较大差距的,这也需要国家通过多种政治和经济改革措施来解决。政策建议：(1)推进收入分配改革,提高低收入人群的收入水平；(2)逐步提高基本医疗保险制度的统筹层次,缩减地域性差异和制度性差异；(3)强化医疗救助作用,重点解决发生灾难性卫生支出家庭的疾病经济负担；(4)加快医疗保险体制改革,促进卫生服务的需求和利用与社会经济发展水平相一致；(5)增强基层医疗卫生服务能力,继续加大对公共卫生服务与基本医疗服务的投入。更多还原

【Abstract】 BackgroundThere is a great population of hypertension in China. The average incidence rate of high blood pressure is38.6%, with more than200million patients. Hypertension disease seriously affects patients’ health, at the same time it also brings heavy economic burden to patients and their families. As it is incurable disease, patients often require lifelong treatments. Therefore, the change of hypertensive disease and the progress of the disease will have great influence on medical costs. In order to reduce individual, family and social disease economic risk, the basic medical insurance system is the most effective, one of the most direct means. As it can provide reimbursement measures to improve health behaviors, enhance health intervention and promote disease outcome from the point of view of economy. In addition,as a matter of policy measures, medical insurance system has the irreplaceable function in improving the accessibility and affordability of medical and health services, reducing the disease economic risk to a great extent, reinforcing social resources allocation, promoting and maintaining social stability and harmony, etc. But we should also be clear that, in our country, the main body of medical insurance system is the basic medical insurance system, andthis system still exist some deficiencies in terms of reimbursement effect and reimbursement fairness. These problems need to be resolved in the process of perfecting, that is the reality basis of this study. ObjectivesThe study aims to evaluate the health service utilization, the cost of the disease, reimbursement for costs, after outpatient and inpatient treatment by field investigation. It also uses conventional indicators to measure the economic burden of hypertension.Based on this, some other aspects such as the effectiveness of reimbursement, reasonable reimbursement and influence factors have also been evaluated. In the backdrop of reform on the medical insurance, the study offers advicesin order to improve the fairness between different medical insurance systems, to improve the ability to resist disease economic risk especially for the poor.DataThe quantitative data of the study mainly comes from the field survey. In the study we adopt a multi-stage random sampling method based on the geographical distribution and socio-economic status. Eight cities (Fushan, Laicheng, Xuecheng, Decheng, Rushan, Gaomi, Ningyang, Shouguang) are selected amoung all the140cities in Shandong province. We choose three urban areas and three villages in each city, and all the hypertensive patients enrolled in the medical institutions belong to the object under investigation. There are9054valid questionnaires in all, and in the question we mainly obtain family general information, disease information and health service utilization relating to the clinic, hospital admission and pharmaceutical use, et al.Methods1Literature reviewSystematical literature reviews are adopted related to the high blood pressure, costs, burden, insurance et al by CNKI, Pubmed, EBSCO and so on. It aims to understand the prevalence of hypertension in China, research methods of economic burden, risk management and so on. In addition, we also make a systematic review in the theoretical and empirical studies relating to economic burden of disease, the fairness of health insurance in and out of China, which to study the currentdevelopment of economic risk evaluation and macro medical insurance design and other aspects of the medical reform.2Data analysis methods(1) Descriptive analysis:we use mean, standard deviation,rate and composition ration for socio-demographic characteristics, disease epidememic characteristics, behavior and lifestyle description.(2) Analysis of disease burden:we use t-test, krusikal-Wallis H-test, Mann-Whitney U-test to measure the health care expenditure and the incidence of catastrophic health expenditures.And we calculate the average distance and relative distance by measuring the catastrophic health expenditure. On the basis of insurance reimbursement, family income, expense of outpatient and hospitalization, we use Probit-model, chi-square test and other statistical methods to make multi-factors test.(3) Reimbursement. We use rate, composition ration and other indicators to describe the distribution characteristics of reimbursement such as the reimbursement level and reimbursement ratio in outpatients and inpatients, while using Theil-index to measure the fairness of reimbursement between different insurances.(4) Utilization health service. We describe the use of health service including outpatient rate and inpatient rate.In addition, standardized method and centralized index are adopted for the fairness in the research which to analyze the influence deriving from the non-economic factors.Results1Economic burden of hypertensionIn this study, the average costs of outpatient and inpatient treatment are570.72RMB and7162.5RMB per year in china. The inpatient cost, especially for rural residences is higher than the result of fourth health services survey. And the drug cost also incurs a certain impact which comes up to565.72RMB per year. 2Catastrophic expendituresAfter inpatient or outpatient treatment, it can cause catastrophic expenditure in about3-5of every one hundred families. The highest proportion comes from the outpatient treatmentand the inpatient treatment cause the mostserious consequences.From the point of economic risk, the low-income families are most affected.3The medical insuranceIn the study, the basic medical insurance makes the most influence. Otherwise some non-basic medical insurances are also effective for excessive medical cost.The multiple regressions show that the health insurance is closely related to the medical cost and utilization. The reimbursement from the medical insurance fund in hospital makes the most proportion which makes up about49.38%on average. The second place comes from the outpatient service reimbursement and the average reimbursement rate is34.81%. The drug reimbursement contributes the least accounted for15.81%.4ReimbursementsThe medical insurance plays a major role in two ways:the number of utilization and economic burden. In the study, it shows that non-disease factors, especially medical insurance, have great impact on the economic burden of hypertension by probit-model. Judged by results, the average level of reimbursements by insurance is350.63RMB, which make up2.16percent of the family income per year. From the perspective of social economy, there is a better effect for a low-cost expenditure and low-income families than others.5Equity evaluationsThe reimbursement for outpatient service is better than that for inpatient service, and both of them have inequalities as the benefit is more conducive for the rich than the poor. In addition, the Theil-index shows that the medical insurance for urban workers is in favor of the allocation of funds.Conclusions and RecommendationsThe hypertension disease would cause some economic losses. And for some families there is no question that the disease will raise economic risks on outpatient, inpatient treatments or drug therapy significantly. The effect arises both with the illness itself and with the other social economy factors.From the perspective of health insurance, the system plays an active role in improving the efficiency and reducing the economic loss. But the study also finds that these effects differ from different systems and different communities. And these problems require a variety of political and economic reform to overcome these inadequacies.Recommendations:(1) to promote the reform of income allocation and progressively increase the income for people in low-income group;(2) to promote the overall plan level of basic insurance system which aims to alleviate coflicts differed across regions and institutional frameworks;(3) to strengthen the role of medical aid especially for the households with catastrophicexpenditures;(4) to accelerate the reform of medical insurance system in order to promote the use of medical service in keeping with socioeconomic development;(5) to enhance the capacity of primary health care service and continue to increase the imput in public health services and basic medical services.更多还原