【作者】 李佳；

【导师】 赵建国；

【作者基本信息】 东北财经大学 ， 社会保障， 2013， 博士

【摘要】 为应对医疗费用过快上涨而导致农民医疗负担过重问题,我国政府于2003年建立并推广新型农村合作医疗(以下简称“新农合”)制度。然而,对农民而言,医疗服务仍然显著存在“一高一低”的特点：“一高”指医疗费用相对较高,即城乡居民医疗服务利用通常面临相近的医疗费用,但在城乡收入差距较大的现实情况下,农民的医疗费用负担明显较重；“一低”指医疗保障水平较低,即城镇职工和居民保障水平明显高于农民。“一高一低”的结果自然是农民所承受的实际医疗费用负担更重,导致放弃治疗或“因病致贫”、“因病返贫”的现象时有发生,农民健康平等权不能得到有效保障。与此同时,农民为降低健康经济风险所采取的预防性储蓄行为又导致居民储蓄率的上升,扩大农民内需便失去了基本动力。因此,不论是从经济发展角度,还是健康平等权利角度出发,政府均必须努力完善作为健康保障机制的“新农合”制度。“新农合”制度的政策目标是解决农民“看病贵”和“看病难“问题,提高农民医疗服务可及性,促进农民医疗服务利用效率,并改善医疗服务利用不平等现状,最终提高农民的健康水平。为实现这一目标,“新农合”制度自建立、推广到普遍覆盖的十年时间里,在融资机制和补偿机制等方面不断进行自我完善与纠正。那么,作为公共产品提供的“新农合”制度对农民“看病难”和“看病贵”现象影响程度如何?是否改善了农民的医疗服务利用不平等现状?农民对“新农合”制度满意吗?如果没有达到政府既定目标,原因又是什么?基于以上思考,本文综合应用政策效果评价及改进理论,按照“文献梳理→政策效果评价综合分析框架构建→实证检验→制度改进”的现代经济学和管理学研究范式,结合辽宁省和大连市的实地调查数据,从医疗服务可及性、医疗服务利用与公平性、满意度评价三个维度,实证评价了“新农合”政策实施成效。最后提出了努力使“新农合”成为农民健康风险管理主要手段的有关思考。论文共分8章,其中第1章为问题的提出,第2章为“新农合”政策实施效果评价综合分析框架,第3章为“新农合”实施效果多层面比较分析,第4章、第5章和第6章分别为政策实施效果评价的实证分析,第7章为基于健康风险管理的“新农合”制度改进的相关思考,第8章为全文总结。第1章：绪论。阐述本研究选题的理论和现实意义,分析国内外研究现状,指出本论文的创新点,概述论文的研究思路和分析框架,介绍主要研究方法,确定论文的基本研究目标和研究内容。第2章：“新农合”政策实施效果评价综合分析框架。本部分为实证分析的结构与逻辑基础。本部分首先梳理政策效果评价及改进理论,为综合分析框架总体的构建提供理论支撑。然后,具体分析各子维度中“新农合”的作用机理,初步确定综合分析框架的逻辑思路。最后明确各维度的研究内容,将各子维度含义具体化,最终构建具体的“新农合”政策实施效果评价的综合分析框架。第3章：“新农合”实施效果多层面比较分析。分别从国家、省级、市级和地区四个方面,利用横截面数据或时间序列数据,系统梳理我国“新农合”历史脉络与实施效果,并从省级、市级和地区方面定性比较分析“新农合”对医疗服务可及性与利用的影响及其可能存在的问题,为后面章节的政策实施效果评价提供现实依据。第4章：“新农合”对医疗服务可及性影响分析。这是政策实施效果评价的第一部分。本章将利用大连市调查数据详细评价“新农合”对医疗服务可及性的影响。鉴于不同农民对医疗服务可及性感受的差异性,并进一步实证分析医疗服务可及性的影响因素。第5章：“新农合”对医疗服务利用及平等性影响分析。这是政策实施效果评价的第二部分。首先,结合辽宁省调查数据详细评价“新农合”对农民医疗服务利用及其不平等的作用。然后,利用大连市调查数据检验“新农合”、医疗服务可及性以及医疗服务利用三者间的理论逻辑关系,即验证是否存在“‘新农合’→提高医疗服务可及性→提高医疗服务利用效率”的逻辑关系。第6章：“新农合”满意度多维度综合分析。这是政策实施效果评价的第三部分。本章将选取直接满意度指标和间接满意度指标具体考察“新农合”满意度现状。具体为：①“新农合”满意度主观评价分析。②参合行为和参合意愿分析。③“新农合”福利认同分析。第7章：基于健康风险管理的“新农合”制度改进。本部分是在政策实施效果评价基础上的制度改进分析。首先,结合辽宁省调查数据初步识别影响农民健康风险的因素。然后,将健康风险管理理念应用于“新农合”实践中,具体考察“新农合”制度供给和农民制度需求间的差异。在此基础上,提出“新农合”制度改进的具体思考,不断完善“新农合”制度,使“新农合”成为农民健康风险管理的有效手段。第8章：主要结论、建议以及未来的研究展望。概括本文的主要结论,并从“新农合”制度内和制度外两方面提出完善“新农合”制度的政策建议,最后提出本文的不足之处以及未来的研究展望,为今后的研究提供一定参考。本文的主要结论有以下几点：①总体而言,“新农合”的有效实施一定程度提高了农民的医疗服务可及性、促进了医疗服务利用效率、改善了医疗服务利用不平等程度,农民的满意度较高。②医疗服务可及性受农民个人特征因素显著影响,“看病难”和“看病贵”因人而异。总体而言,农民更关注“看病贵”,而非“看病难”。门诊和住院报销经历均有的农民对“新农合”缓解“看病贵”和“看病难”问题感触更深。③对于农民而言,“看病难”难在重大疾病治疗难。具体体现在乡镇医院卫生资源稀缺,县级医院大病诊疗能力有限,而市级及市级以上医院医疗资源紧张。“看病贵”贵在诊治大病所需费用较多,而实际报销水平较低。④农村居民确实存在医疗服务利用不平等现象,医疗服务并没有以需求为导向进行资源配置。尽管“新农合”改善了医疗服务利用的不平等现状,促进了低收入群体的医疗服务利用,但收入水平仍然是医疗服务利用不平等的主要因素。⑤医疗服务可及性差影响了农民医疗服务利用效率。验证了医疗服务可及性与医疗服务利用之间的理论逻辑关系。因此,不断缓解农民“看病贵”和“看病难”的主观感受能够提高农民的医疗服务利用效率。⑥农民主观满意度评价受实际获益程度等因素直接影响。而收入因素不再是影响参合行为的主要因素,医疗服务的便利性是参合意愿的重要因素。农民福利认同度与个人信息认知和报销水平等多个维度正相关,而健康不佳者福利认同较差,说明应该加大对贫困群体的政策扶持,提高其福利认同。⑦从健康风险管理角度看,“新农合”制度的补偿广度(补偿范围)需要扩大、补偿深度(补偿水平)需要深化、补偿机制(大病补偿)需要完善。社会需要逐渐树立健康风险管理理念,重点是应将目前主要强调疾病治疗向疾病预防的理念转变。与此同时,尤其要关注农民贫困群体的健康风险。本文主要创新之处有：①构建“新农合”政策实施效果综合分析框架,丰富了“新农合”政策效果评价体系。基于“新农合”的改革目标和“新农合”的作用机理分析,按照“‘新农合’→医疗服务可及性→医疗服务利用及平等性→农民满意度→制度改进”的逻辑关系具体构建“新农合”政策实施效果评价综合分析框架。该分析框架丰富了“新农合”政策效果评价体系,并利用相关调查数据,从农民需求视角多角度系统评价了“新农合”的政策实施效果,有利于发现“新农合”制度制定与制度执行中存在的问题,不断完善“新农合”制度。②具体明确了医疗服务可及性的含义和度量,延伸和深化了医疗服务可及性概念。医疗服务可及性评价是已有“新农合”研究的重点内容。但对可及性的研究仍以定性分析为主,定量分析尚不多见,与此同时,对可及性的度量也仅限于客观评价,其实客观评价的指标选取又常带有主观倾向,因此,对可及性的具体度量仍需深化。本文尝试从农民的主观评价角度出发,用农民的“看病贵”和“看病难”主观感受分别度量医疗服务的“需方可及性”和“供方可及性”,“需方可及性”差的最直接结果就是造成农民的“看病贵”问题,“供方可及性”差的最直接结果就是造成农民的“看病难”问题。鉴于农民医疗服务可及性认知和个人主观感受密切相关,因此,该度量方法不仅能深刻体现可及性程度的个体差异特征,同时也能深化对可及性的相关研究,如本文的可及性影响因素分析和可及性与医疗服务利用关系分析均具有一定的现实意义。③将健康风险管理理念引入“新农合”制度改进分析中,拓宽了健康风险管理理论的应用,也为“新农合”制度的改进提供了新思路。“新农合”作为农民的最重要的健康保障机制,但已有研究过多强调的是农民所面对的健康经济风险,而对疾病预防研究仍很欠缺。健康风险管理理念不仅考察健康风险的应对,而且考察健康风险的识别与评估,因此是对农民健康风险的全面审视。本文结合健康风险管理过程,详尽考察制度供给和制度需求间的差异,据此提出“新农合”制度改进的相关思考,不仅深化了健康风险管理理论在“新农合”制度中的应用,提出将疾病预防工作融入“新农合”制度改革中的思考也为我国“新农合”制度的改革提供了新思路。④“新农合”的福利认同分析,进一步丰富了满意度评价维度。已有研究主要分别从农民主观评价和参合意愿两个角度进行单独分析,本文不仅结合这两个角度进行了综合研究,而且进一步引入福利认同概念,将“新农合”视为农民福利的一部分,进而从福利经济学视角拓展和深化了满意度评价维度,不仅丰富了满意度评价体系,也能从多维度视角分析农民的满意度状况及其影响因素,为进一步提高农民的满意度提供参考。囿于数据获取困难的缘故,本文尚缺乏有关“新农合”对医疗服务质量影响的研究,也没能从动态角度考察“新农合”政策实施效果。“新农合,,制度是我国医药卫生体制改革系统中的重要一环,必须围绕医药卫生体制改革的顶层设计作出统筹安排。将健康风险管理理念与“新农合”相结合是本文的初步尝试,但具体机制设计仍需要理论的不断创新和实践的反复检验。更多还原

【Abstract】 Chinese government established and promoted the New Rural Cooperative Medical Scheme (hereafter referred to as "NRCMS") in2003to tackle farmers’overburdened medical services caused by the rapid rise of medical costs. However, for farmers, medical services are still characterized by "one highness and one lowness":"Highness" refers to the relatively high medical costs, i.e. typically hospitals charge almost similar medical expenses for medical services from urban and rural residents, but as urban-rural income gap is getting larger, farmers undertake significantly high medical costs;"lowness" refers to the relatively low level of medical care, that is, medical service for urban workers and residents is obviously better than farmers."One highness and one lowness" naturally results in the fact that farmers actually bear heavier medical costs, leading to the frequent treatment withdrawal or illness-related poverty, thus the health equality rights of farmers cannot be effectively guaranteed. Meanwhile, the precautionary savings behavior that farmers take in order to reduce health economic risks lead to the rise of household savings rate, which reduces the basic driving force of expanding farmers’domestic demand. Therefore, whether from the perspective of economic development or health equality rights, government must strive to perfect the NRCMS, which is a health security mechanism.The political aims of the NRCMS are to solve the difficulty of expensive medical treatment problems, and improve the medical services accessibility and efficiency. The improvement of unequal status in medical services is also the goal of the NRCMS. In addition, the final goal is to improve the standard of peasants’health. During the ten years which is from the establishment, promotion to universal coverage, the experts corrected and completed the system constantly in the aspect of financial system and the compensating mechanism and so on. So, as a public product, what is the degree of influence about the NRCMS on the difficulties of getting medical services and high cost? Whether did it already improve the unequal utilization status of the farmers’medical services or not? Did the farmers really satisfied with the NRCMS? And if the government did not reach the goals, what is the reason?On account of the above deliberations, this dissertation mainly adopts the theory of policy evaluation and improvement. In accordance with the paradigm of modern economics and management science from "literature review→policy-testing system construction →empirical test→system redesign", through combining the survey data of Liaoning province and Dalian City, as well as the accessibility, utilization, satisfaction of medical services in three dimensions, the author examines the effects of reform of the NRCMS in detail. Then the author ultimately puts forward the thinking to make the NRCMS becoming the main means of farmers’health risk management.This dissertation comprises of eight chapters, in which the first chapter proposes problems; the second chapter constructs the framework for the comprehensive analysis of the effects of the NRCMS; the third chapter analyze the effects of reform and policy testing of the NRCMS comprehensively; the fourth, fifth and sixth chapters focus on empirical analysis of policy testing respectively; the seventh chapter concentrates on deliberations of redesigning of the NRCMS from the perspective of health risk management; and the eighth chapter serves as the summary of this dissertation.Chapter one is the Introduction. The author states the theory and the practical significance of this thesis. Also the innovation of this thesis is illustrated on the base of the analysis of research status at home and abroad. In addition, the author also states the ideas and analytical framework, introduces the main research methods, and determines the goal and the content of this thesis.Chapter two, the author establishes the comprehensive framework of the examination of the NRCMS reforming effect. This part first summarizes the policy effect evaluation and improvement theory which providing the theoretical support for integrated analysis framework. Then, it specific analyze the mechanism of the NRCMS in various dimensions, and preliminarily clarify the theory logic thinking of the comprehensive analysis framework. Finally the author clear and specify the research content of each dimension, and establishes the comprehensive framework of the examination of the reforming effects finally.Chapter three is the comparative analysis of implementation effect of NRCMS. Based on the real situations of the country, provincial, district and local conditions, the paper will comb the implementation effect of the NRCMS in the process by using cross-sectional data and time series data. The paper also analyzes the impaction of NRCMS on the accessibility and utilization of medical service and the possible problems from the perspective of country, provincial and local conditions. This section provides realistic basis for the evaluation of the policy implementation in later chapters. Chapter four analyzes the impacts of the NRCMS on the accessibility of medical services. This chapter is the first part of the evaluation of the effect on policy implementation, which tests its impacts on the accessibility of medical services on the basis of survey data of Dalian City. Due to the diversity of farmers feel the differences on health services accessibility, the author further analyzes the influencing factors the accessibility of medical services.Chapter five elaborates on the impacts of the NRCMS on the utilization and equality of medical services, which is the second part of the evaluation of the effect on policy implementation. The author first evaluates the inequality of medical service utilization by combining with survey data of Liaoning Province. Then, the author verifies whether there is a logical relationship of "the NRCMS→improvement of accessibility of medical services→promotion of medical service utilization and equality" by using the data of Dalian City.Chapter six focuses on the comprehensive analysis of satisfaction evaluation of the NRCMS, which is the third part of the evaluation of the policy implementation. This chapter will use three sub-dimensions to further analyze farmers’ evaluation of satisfaction of the NRCMS, namely, analysis of influencing factors of satisfaction evaluation, analysis of participation behaviors and willingness to join the NRCMS, and analysis of influencing factors of welfare recognition.Chapter seven is about the amelioration of NRCMS based on health risk management. This section is a continuation of the evaluation of the policy implementation. Combined with the survey data of Liaoning Province, a preliminary identification of the factors that affect farmers’ health risks could be made. The NRCMS could be decomposed with the health risk management process, and the difference between supply and demand could be found from the perspective of the system’s supply and demand. On this basis, the author puts forward the concrete thinking to make the NRCMS as an effective means for health risk management of the farmers.Chapter eight comes to the main Conclusions, suggestions and Research Prospects. The chapter summarizes the paper and comes to the conclusion, presents suggestions for ameliorating the NRCMS in light of intra-policies and extra-policies and finally points out the deficiencies and the prospects of the research.Main conclusions of this dissertation include: (1) Overall, the effective implementation of the NRCMS enhances the accessibility of medical services, and promotes the efficiency and the utilization inequality of medical service to a certain extent. The farmers are more satisfied with the NRCMS than ever before.(2) The accessibility of medical services influences by farmers’ personal characteristics significantly. The difficulty of expensive medical treatment problems differs from man to man. Overall, farmers are more concerned about the expense, rather than the difficulty of getting medical service. The farmers have deeper feelings to the difficulty of expensive medical treatment problems.(3) The difficulty of getting medical treatment problems mainly focus on the major disease treatment to the farmers. This embodies in the scarcity of hospital health resources in towns, the limited ability of hospital diagnosis and treatment in countries, and the scant medical resources in cities. While the difficulty of medical treatment problems lies in the high cost of the treatment of a serious illness, and the low actual reimbursement.(4) The unequal status in medical services exists in rural areas, and medical services are not configurated by the demand. Although the NRCMS improves the unequal status and the utilization of medical services, the income level is still the major factor in inequality utilization of medical services.(5) The medical services accessibility and efficiency influence the utilization of medical services. It verified the logical relations between the accessibility and the utilization of medical service. Therefore, the relieved feelings to the difficulty of medical treatment problems will improve the efficiency of rural medical service.(6) The actual benefit influences the evaluation of farmers’subjective satisfaction directly. And the efficiency of medical service, instead of the income, becomes a major factor. The welfare of the peasant’s identity is related to many factors such as personal information cognition, the degree of reimbursement and etc. The welfare identity of the people who has a poor health is worse. This explains the reason why the policy support for poor should get increased and further improves their welfare.(7) From the perspective of the health risk management system, the compensation range of the NRCMS needs expansion, the compensation level needs deepen, and the compensation mechanism needs to be perfect. Society needs to establish a healthy concept of risk management gradually, and the concept transformation which disease treatment to disease prevention should be emphasized. At the same time, the government should pay attention to the health risk of the poor especially.Main innovations of this dissertation include:(1) Construction of the framework of a comprehensive analysis for testing the effects of the NRCMS policy. On the basis of the reforming target and the mechanism analysis of the NRCMS, and in accordance with the logical relationship of "the NRCMS→improvement of accessibility of medical services→promotion of medical service utilization and equality→enhancement of farmers’ satisfaction", the first attempt is made to build a specific framework of a comprehensive analysis for the NRCMS policy testing in the three dimensions of accessibility of medical services. From the perspective of farmers demand, the analysis framework enriches the evaluation system of the NRCMS policy effect by using the related survey data, which is helpful to find the problems, and further improve the system of the NRCMS constantly.(2) This paper clarifies the meaning and the measurement of the medical services accessibility, extends the concept of it. The evaluation of medical services accessibility is the key content of the existing researches about the NRCMS. While the studies about the accessibility still give priority to the qualitative analysis, instead of the quantitative analysis. At the same time, the measurement of the medical services accessibility is limited in objective evaluation, while the criterion of the objective evaluation often comes with subjective tendency. Therefore, the specific measurement of accessibility still needs to deepen. This paper attempts to measure the accessibility by using the farmer’s feeling to the difficulty of medical services from the angle of the farmer’s subjective evaluation. The most direct result that caused by bad "buyer’s accessibility" is the high cost of medical services, and the bad "supplier’s accessibility" results in the difficulty of getting medical services. Since the medical service accessibility is closely related to personal feelings, therefore, this method not only reflects the profound individual characteristics, but also deepens the relative researches on accessibility. Such as both the analysis of the influencing factors on the accessibility and analysis about the relationship between accessibility and medical services utilization in this paper have a certain practical significance.(3) The author adds the health risk management into the analysis of the NRCMS, broadens the application of health risk management theory, and provides a new way for the improvement of the NRCMS. Although the NRCMS is the farmer’s main health security mechanism, the existing researches are mainly emphasis on the health economic risk instead of the disease prevention. Health risk management not only studies the response to the health risk, but also studies the recognition and evaluation of it. So it is a comprehensive review of the health risk. The author finds out the difference between supply and demand could be found from the perspective of the system’s supply and demand in the process of the health risk management, and further puts forward the concrete thinking to improve the NRCMS.The paper not only deepened the health risk management theory in the application of the NRCMS, but also provides a new way for the reformation of the NRCMS.(4) The welfare analysis of the NRCMS further enriches the satisfaction evaluation. The existing researches study the farmers’evaluation of satisfaction of the NRCMS and the participation willingness to join the NRCMS separately. This paper not only combines of these two aspects, but also further introduces the concept of welfare identity, regards the NRCMS as a part of the farmer’s welfare, and then expands the satisfaction evaluation from the perspective of welfare economics. All of this not only enriches the satisfaction evaluation system, but also analyzes of farmer’s satisfaction and the influencing factors from multiple perspectives, further provides the reference for farmer’s satisfaction.Restrained by the data-obtaining possibility, the paper is still in lack of the research on the influence of the NRCMS" on the quality of medical care services.In addition, coherent and continued data are urgently needed to dynamically follow the reform outcome of the NRCMS. The reform of the NRCMS constitutes an important part of China’s reform of medical care system and overall arrangements are demanded centering on the top-level design of the medical and health care system reform. The fusion of sound risk management and the NRCMS is a preliminary try of the paper, but the formation of concrete mechanism still requires innovation in theory and continuous tests by practices.更多还原