【作者】 贾红英；

【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， 2014， 博士

【摘要】 研究背景医疗保障发展水平和经济水平的提升使得医保患者就诊人群的数量不断扩大,医保患者就诊医疗费用的增长问题也越来越得到重视。此外我国还面临着工业化、城镇化、人口老龄化、经济全球化、疾病谱变化和生态环境变化等复杂的外部环境,这些社会问题的出现也会给我国的卫生工作带来较大的挑战,在多种内外因素的共同作用下,医疗卫生费用在未来一段时间内仍然存在继续快速上涨的可能。医疗保险支付制度的改革是当前医疗保障体系的核心,也是我国医疗卫生体制改革的一个热点问题,作为沟通医疗保险制度改革、医疗机构改革与药品制度改革重要纽带,它是有效遏制医疗费用快速上涨、促进有限医疗资源的合理分配和引导患者合理就医的有效经济手段,在整个医疗保险体系中占据重要地位,其支付的合理性也将直接影响到医保制度的效果。在“十一五”期间,以医疗保障体制改革为代表的社会改革已经全面展开,并且取得了显著地社会成效,经济发展与社会发展不匹配的窘境得到一定缓解。在“十二五”期间,我国的基本医疗保险要继续向深度领域发展,支付方式改革作为社会资源二次分配的一种有效方式,其在合理控制医疗服务费用、维护医疗卫生服务的可及性与可负担性、保障参保人群利益分配的作用已经被人们所逐步认识。因此,在下一步制度导向中应在积极拓展保险服务领域、丰富保险产品、挖掘保险服务潜力的同时,尊重社会群体中多数人群的非规范利益表达,努力通过制度措施来化解不同社会阶层之间的利益矛盾,实现市场经济条件下的平衡、有序的均衡机制的建立,重建社会基础秩序,促进社会保障体系的全面健康发展。研究目的以胆囊切除术为例,分析历年来住院总费用和主要费用构成之间的变化,计算各费用构成与总费用之间的关系,从而发现胆囊切除手术费用上涨的来源和表现,为下一阶段围绕推广临床路径管理、加大药品价格控制力度和改革医保支付方式等综合医疗费用控制措提出相应的改进建议。资料来源与方法1、资料来源定性资料：利用CNKI、万方、维普、EBSCO、PUBMED、MEDLINE等数据库查阅相关期刊、论文资料；浏览人力资源与社会保障部、财政部、卫生部、欧盟、英国和德国卫生部等政府网站,收集国内外关于医保政策方面的材料、统计年鉴、统计公报等信息；通过百度、谷歌等搜索引擎,查阅我国基层医保管理部门出台的关于医保支付方式和费用控制等方面的创新举措；查阅商业保险机构制订的关于医疗保险类别、内容、级差支付比例情况,了解保险精算学在微观医保政策方面实际运用和调整。定量资料：主要收集2008—2013新疆自治区人民医院、山东大学齐鲁医院、山东大学第二医院、山东省立医院4个单位胆囊结石伴慢性或急性胆囊炎患者行开腹或腹腔镜胆囊切除术的住院首页信息,包括患者一般信息、诊断、手术情况、预后情况、住院费用等。2、方法(1)文献复习法主要侧重理论部分的研究,主要对搜集到的信息进行内容研究,既要获得宏观范围(政策体系、医保基金、配套制度等)抽象的结论,也要了解微观范畴(定点医疗机构、参合患者等)的运行变化。具体研究的内容包括：中国城乡基本医疗保险制度历史沿革、国内外关于医疗保险制度的理论、中国城乡多元医保格局的成因、门诊住院费用构成及变化趋势。(2)资料分析方法利用SAS9.2统计分析软件,分别应用t检验、z2检验、方差分析、DUNCAN法、多元线性回归等方法进行单因素分析、多因素分析,探讨胆囊结石伴慢性或急性胆囊炎患者行开腹或腹腔镜胆囊切除术治疗的住院费用的影响因素,并进行了临床经济学评价,为合理有效的配置有限的卫生资源提供理论依据。结果1、乌鲁木齐和济南地区两种胆囊切除手术方式费用均存在差异。2、两地住院费用均呈现上涨趋势。3、中药费用在乌鲁木齐地区所占比例较高。4、行腹腔镜胆囊切除手术的住院费用低于行开腹手术的住院费用,降低的部分主要来自于西药费用。5、技术性收费在住院总费用中所占比例较低。结论与建议乌鲁木齐、济南两地医疗费用均出现上涨,尤其是开腹手术患者的住院费用上涨明显,这提示胆囊切除手术患者的疾病经济负担逐年上升。从费用构成来看,西药费、诊疗费和其他费用在总费用所占比例较大且增长速度较快,这提示此类费用是下一阶段医疗费用控制的重点。政策建议方面首先需要加大临床路径管理的力度,逐步提高技术性医疗服务的价格等,尽快调整不合理的医疗费用形成机制,有效控制费用的快速上涨。同时还需要加大对药品招标采购的干预力度,有效控制中标价格；逐步转变按项目付费的落后支付方式,提高医保基金使用的科学性。通过加大“三医联动”的改革力度,不断调整医疗费用的不合理构成,促进正常医疗服务运行体系的建立。更多还原

【Abstract】 BackgroundAs the development of the basic health insurance and socioeconomic, the Medicare patients are increasing and incur the excessive increase in medical costs. However, the medical insurance system is facing many difficulties such as aging and disease spectrum. All those make it possible that medical costs will continue to rise in the future.The paying mode becomes a hot issue for health reform and should be carried out to control the unreasonable rising of expenditure. As the connection between the reform of medical institutions and pharmaceutical, the rationality of the paying mode plays an important role which can directly affect the whole medical insurance.During the period of11th Five-Year Plan, the system of medical insurance starts to be innovated and has obtained remarkable achievements. As a tool of resource allocation, it will keep developing and deal with a wide cross-section of society. In the next period, the medical insurance will expand the areas and mining the service potential which aims to conflict resolution and promote the social security system.Objectives1. To acquire the background information of the foundation and development history of basic health insurance in our country. And then to summarize the model cases of paying reform and expense control related to the medical insurance which aims to understand the relationship between paying mode and expense control.2. To make systematic summarizing of medical insurance in paying through literature review which to found out the major trend and useful proposals for the basic health insurance system of china.3. To take the example of cholecystectomy in order to analysis the quantity and performance of charges. On the basis of that, a control mode of payment will be carried out and a set of advice will be offered.Data and Methods 1. dataThe qualitative data mainly comes from CNKI、EBOSCO、 PUBMED et al which takes the key word of medical insurance for urban workers or new rural co-operative medical system. Moreover, the website of ministry of finance or health should be viewed to collect the information of statistic bulletin. And the commercial insurance institutions also should be caused concerned about the insurance actuarial.The quantitative data mainly comes from the medical records which root in four big hospitals of Xinjiang and Shandong provinces. The medical record contains the basic information of the patients, the diagnosis, costs and so on.2. Methods(1) Literature revi ewMost information uses the qualitative study to be analyzed in terms of content to find out the macro and micro changes such as the historical origin, institutional theory, cost composition and change trend.(2) Statistic methodWith the application of single factor and multi factors analysis, the surgery cost, factors and economic evaluation are investigated which in favor of allocation of health insurance resources.Results1. The expenditure between Xinjiang province and Jinan has great difference in two kinds of cholecystectomy. One-way analysis results show:age, sex, nation and operation model et al are the main factors of the cost.2. The cost in Urumqi and Jinan both rise from2008and the major source of the growth comes from the western medicine, diagnosis and others.3. The cost of Chinese medicine covers a large proportion in the city of Urumqi which is more than1000RMB.4. The cost of laparoscopic surgery for cholecyst is less than that of abdomen surgey which mainly due to less use of western medicine.5. The low fee of technology including the opretion cost and care cost which covers less than20%of the total expenditure. and the absolute value keeps declining.Conclusions and RecommendationsInfluencing factors for expenditure are multidimensional which related to the disease itself but also the social factors. As it shows from the research, the cost of western medicine, diagnosis and others play the leading role in cost increasing, so the basic health insurance should adjust the direction of compensation. What’s more, comprehensive reform should be implemented especially for promoting the clinical path and increasing the price of technical medical service which to change the unreasonable formation mechanism of price.更多还原