【作者】 王丽；

【导师】 申俊龙；

【作者基本信息】 南京中医药大学 ， 中医医史文献， 2013， 博士

【摘要】 随着人类科学技术的进步和卫生条件的改善,人的期望寿命日益延长,使得老年人口在总人口中的比重逐渐增加,伴之而来的是慢性非传染性疾病逐渐增多,慢性病已经成为一个全球性问题,它不仅仅带来医疗费用的增长,还造成人们,尤其是老年人群的失能和生活质量的下降,其地位也越来越凸显重要。正如世界卫生组织指出的那样,慢性病患病率的增高已经威胁到很多国家社会和经济的发展,以及人们的生活和健康。慢性病需要长期维持性治疗,医疗费用高,导致“因病致贫、因病返贫”在现阶段愈发突出。这不仅是一个经济问题,也是一个严重的社会问题。近年来发生的一系列媒体热点事件,引发社会对于慢性病医疗保障的关注。如何保障慢性病患者的医疗需求?国际经验证明,单纯依靠增加财力投入并不能解决医疗保障问题,更重要的是卫生资源如何高效利用。由于医疗服务具有复杂的技术经济特征和高度专业性,医、保、患三方信息的不对称,市场机制难以调节全社会医疗卫生服务供需总量,这就容易造成卫生资源不能得到合理的利用。因此,医疗服务必须置于严格监控与管理下。规制经济学是以微观经济学和产业组织理论为基础,吸收相关研究成果而发展起来的一门学科。随着规制经济学的发展,研究主体主要是规制执行部门,需要发挥各规制主体的协同作用,不能偏废,需要使用规制经济学对慢性病医疗服务的政府规制进行研究。要通过卫生经济学评价方法选择更具成本效果的治疗方案,并在医疗机构提供服务过程中,引导优先治疗方案的使用。本研究选取终末期肾病为例,应用临床医学、流行病学相关理论,对终末期肾病及其治疗特点、流行病学变化趋势以及透析治疗组织和提供进行梳理；在规制经济学理论等相关理论的指导下,对终末期肾病医疗服务供方行为进行评价和监督管理,对透析治疗进行卫生经济学评价,寻找具有成本效果的治疗方式；在卫生公平和福利公正理论、激励规制理论等相关理论指导下,对我国终末期肾病透析治疗的医疗保障、医保支付政策的完善进行理论探讨。在文献研究和专家咨询法基础上,确定病例入选标准,完善了调研问卷；选择东、中、西部各一个省会城市的医学院附属医院：浙江大学第一附属医院、安徽医科大学第一附属医院、安徽省立医院、西安交通大学第一附属医院进行现场调研,主要内容涉及一般状况、透析治疗成本、疾病负担、临床疗效、生存质量、医疗保障状况等。由于本研究采用非随机化对照试验的设计方法,在对资料处理时,采用倾向评分匹配法对血透组和腹透组的数据资料进行处理,使其在可控变量上达到组间均衡；应用作业成本法分别测算腹透、血透治疗的成本；应用疾病经济负担理论测算两种透析治疗的直接医疗费用、直接非医疗费用、间接费用；分别应用临床指标及生命质量得分这样的主、客观指标评价透析的临床疗效；采用多元回归分析法分析!生命质量的影响因素,以及透析费用的相关影响因素；应用K-M生存分析,比较血透和腹透的生存时间是否有统计学差异；应用Cox比例风险回归模型,对透析治疗的生存时间进行多因素分析。调研资料均使用SPSS17.0统计软件进行整理和分析。通过理论研究和实证研究相结合,得出以下结论：(1)卫生服务公平性差,部分患者因经济原因减少透析剂量或举债透析；(2)ESRD透析治疗经济负担沉重,要优先选择成本-效果佳的腹透治疗,政策应予以倾斜；(3)医疗机构提供透析服务的倾向性对患者治疗方案选择具有显著影响,应加强对医疗机构的监管；(4)尽管我国的医疗保障一定程度上减轻了患者的经济负担,但ESRD医疗保障目前仍存在补偿范围窄,水平低、公平性差的问题,需进一步完善；(5)应使用规制经济学理论指导科学、合理的医保支付方式,提高医疗资源的利用效率。最后分别从医保部门、卫生行政管理部门、医疗机构和社会四个角度,提出政策建议。包括：积极推行慢性病健康教育、完善城乡一体化的基本社会医疗保障体系,同一受益标准、提出尝试采用总额预付制和按服务人次付费的组合支付方式来优化医保支付方式、合理区域卫生规划,实行社区和专科医院联动的双向转诊患者管理模式、加大科研投入,鼓励相关主要产品国有化、加强医院成本核算与控制,降低医疗费用过快增长等。更多还原

【Abstract】 With the progress of science, technology, and the improvement of health condition, people’s life expectancy is increasingly extending, which makes the proportion of elderly population in total population gradually increased, accompanied by increasing chronic noncommunicable diseases. Chronic noncommunicable diseases has become a global problem, which not only leads to the growth of medical expenses, but brings about people, especially the elderly’s disability and descending quality of life, It deserves more and more attention. As the World Health Organization points out, the increasing prevalence rate of chronic diseases has threaten many countries’ social and economic development, as well as people’s life and health. Chronic diseases require long-term maintenance treatment and high medical cost, which renders "poverty due to illness, illness due to poverty" increasingly prominent at this stage. This is not only an economic problem, but also a serious social problem. In recent years, a series of hot news exposure by media brought end-stage renal disease patients’ medical security to the attention of the society. How to ensure the medical needs of patients with chronic diseases? International experience has shown that relying simply on increasing financial funding does not solve health care problem, what’s more important is how to use limited health resources efficiently.Due to the medical services’ being complex and highly specialized, medical institutions, medical insurance departments and patients each entertain asymmetric information. It is difficult for the market mechanism to adjust supply and demand of the total health service, which tends to cause the unreasonable use of health resources. Therefore, the medical service must be subject to strict monitoring and management. Regulatory economics is based on microeconomics and industrial organization theory, absorbing the relevant research results to develop. Along with the development of the regulation economics, the study is mainly on the enforcement agencies, whose synergy shall be brought into play, and cannot be ignored. It’s necessary to apply regulation economics to study government regulation of chronic diseases medical services. We should use economics evaluation method to choose more cost-effective treatment, guide the use of the prioritized treatment in the process of medical services provided by medical institutions.This study selects end-stage renal disease as an example, applying clinical medicine, epidemiology, and the related theory to comb its treatment characteristics, epidemiological trend and dialysis treatment organization and provision. Under the regulation economics and related theory, it is to evaluate and supervise the provider’s behavior, conduct economic evaluation of dialysis treatment, to seek more cost-effective treatment. Under the guidance of theory, such as health equity, welfare justice and incentive regulation theory, it is to study how to improve medical security of end-stage renal disease, and to optimize medical security payment pattern in our country. Based upon the literature study and expert consultation, we determine the cases selection standard, and perfect the investigation questionnaire. Through the non-randomized controlled trials study design method, we choose hospitals in the capitals of eastern, central and western provinces, which are all medical school affiliated hospitals: Zhejiang University First Affiliated Hospital, Anhui Medical University First Affiliated Hospital, Anhui Provincial Hospital, Xi’an Jiaotong University First Affiliated Hospital respectively, with the main content involving patients’ general condition, dialysis treatment cost, the burden of disease, clinical curative effect, quality of life and the status of health security, etc. Because this study is based on a design method of non-randomized controlled comparative trials research, we use propensity score matching method to handle the data for two groups, abominate groups so as for controllable variables from the two groups to achieve balance; we use ABC method to calculate the dialysis cost in two dialysis centers respectively; apply disease economic burden theory to calculate two dialysis direct medical cost, direct non-medical cost, indirect cost; apply subjective and objective index of clinical indicators and life quality score respectively to evaluate the curative effect of dialysis;use multiple regression analysis method to analyze the influence factors for quality of life, and related influence factors for the cost of dialysis; apply K-M survival analysis to compare HD and PD survival time to see whether there exists statistic difference; apply Cox’s proportional hazards regression model to analyze multiple factors of dialysis survival time, and apply SPSS17.0statistical software to collect and analyze research data.Through the theoretical research and empirical research, we draw the following main conclusions:(1) dialysis treatment equity is poor, while some patients reduce dialysis dose, or have the treatment by getting into debt due to financial reasons;(2) F.SRI) financial burden is heavy, we should give priority to cost-effective peritoneal dialysis treatment, towards which policy should be tilted;(3) medical institutions with their propensity have great influence on patients’choices, we should strengthen the supervision of medical institutions’ conduct;(4) although our country’s medical security reduces ESRD patient’s financial burden to a certain extent, but there still exists medical security compensation with narrow coverage, low level and poor fairness, which need to be further optimized;(5)regulation economics shall be applied to build scientific and reasonable medical security payment method, improve efficiency in the use of medical resources. Finally, we present suggestions in terms of the health security department, the health administrative department, the medical institutions and the society respectively, including:promoting health education actively, improving the integration of basic social medical security system in urban and rural areas, and implementing the same benefit standards, introducing the combined payment system of global budget and flat rate to optimize the medical security payment, rationalizing regional health planning, implementing community and specialized hospital linkage of two-way referral management pattern, increasing funding in the scientific research, encouraging nationalization of related main products for chronic non-communicable diseases treatment, strengthening the hospital cost accounting and control, and reducing excessively rapid growth of medical costs, etc.更多还原