【作者】 马骋宇；

【导师】 孟庆跃；

【作者基本信息】 山东大学 ， 社会医学与卫生事业管理， 2010， 博士

【摘要】 一、研究背景新农合(以下简称“新农合”)是由政府组织和支持,农民自愿参加,大病统筹为主,农民互助共济的合作医疗方式。由于参保农民多,覆盖面广,应用管理复杂,依靠手工处理无法满足管理需求。因此,在各级政府的支持下,以现代计算机、数据库、网络技术为基础的新农合管理信息系统逐步建设起来。信息化建设是新农合提高工作效率,确保基金安全和规范运行,实现科学管理的有效手段。经过中央及地方政府几年来的努力,新农合管理信息系统已经有了一定的发展。但随着信息化工作的逐渐深入,新农合管理信息系统建设中的问题也逐渐显现,主要表现为：信息系统辅助决策的支持作用没有充分发挥；资源配置不均衡,存在重复开发；人员不足,专业素质不高；管理不规范等。已有的关于新农合管理信息系统的研究,缺少对新农合管理信息系统决策支持技术的讨论,针对新农合管理信息系统开展的实证研究也较少。根据对样本县的调研,本文分析了新农合管理信息系统发展的现状和存在的问题,针对新农合管理信息系统决策支持能力不足的问题,分析、设计了决策支持系统的框架。并以筹资补偿为例,设计实现了新农合筹资补偿辅助决策软件SimIns,利用SimIns提供的数据分析和辅助决策支持,作者对山东省东阿县的筹资补偿方案进行了分析和测算,并给出了方案的调整建议。二、研究目的本研究的目的是通过开发和使用新农合决策支持技术,完善新农合管理信息系统服务。具体的研究目的包括：1.通过深入分析目前新农合管理信息系统现状,提出新农合决策支持系统信息化和电算化的基本框架和思路；2.以新农合资金补偿为例,研制和开发新农合辅助决策软件.新农合筹资补偿模拟决策软件SimIns。3.利用SimIns已开发完成的新农合筹资补偿辅助决策模块,在样本县进行实际应用。三、资料来源和研究方法(一)资料来源本研究采集了现场资料,主要用于分析新农合管理信息系统现状、完成抽样县数据集、利用数据进行新农合补偿信息决策模块的模拟等。资料主要来源于两部分,即已有资料和调查获取资料。已有资料包括：①各调研县(市、区)新农合管理办公室提供的2005-2008年新农合制度的运行情况和政策文件；②山东省2004-2008年新农合试点县(市、区)工作年报统计表；③欧盟资助项目“中国和越南建立公平性和可持续性农村健康保障制度研究2008年家庭入户调查、机构调查；④有关文献。本研究调查资料包括：①调研县(市、区)2005-2008年的社会、经济和人口发展情况；②调研县(市、区)2005-2008年的新农合补偿方案及补偿情况调查；③调研县(市、区)政府领导、卫生行政部门和合作医疗经办机构管理人员问卷调查及非正式个人访谈；④山东省2005-2008年新农合调研县(市、区)基金管理信息平台数据库文件。(二)抽样和资料收集方法资料收集方式包括家庭入户调查、知情人员非正式访谈和机构调查。1.家庭调查抽样按照分层随机抽样的方法,抽取山东省和宁夏回族自治区社会经济发展状况较好、中等和较低的各三个县。在考虑了地理分布等因素后,在山东省抽出了经济相对发达的济南市章丘市、经济中等发达的潍坊市昌乐县、经济欠发达的聊城市东阿县；在宁夏回族自治区抽出了经济相对发达的青铜峡市、经济中等发达的银川市永宁县、经济欠发达的吴中市中宁县。在这6个县(市)中,按照相同的抽样原则,每个县抽出三个乡镇,每个乡镇再按照经济发展水平的好、中、差各抽出2个村。基线调查于2006年5月进行,共6137户家庭。最终调查于2008年9月进行,抽取了3288户家庭。采用入户问卷调查的方式,每户的所有家庭成员均为调查对象。设计家庭调查表,由中心的研究生担任调查员,以面对面访谈方式填写家庭调查表。调查内容包括家庭一般情况、居民健康及卫生服务利用情况、就诊情况、调查前一年内住院情况、对新农合认知意向情况。最终将这些信息整理、汇总在样本县的新农合数据库中。2.知情人员非正式访谈对调研县(市、区)政府分管领导、卫生局、合作医疗管理人员、医疗机构工作人员、新农合管理信息系统操作人员就有关问题进行有侧重的非结构化访谈,了解他们对新农合信息系统的认知、看法,考察新农合信息收集及计算机应用完成情况及管理人员在操作过程中发现的问题。3.机构调查设计调研县(市、区)新农合补偿调查表,由调研县(市、区)合作医疗管理办公室及民政、财政等相关部门填写。主要调查内容包括社会、经济状况,参合情况、基金筹集及支出情况、门诊(住院)补偿受益情况等。另外,作者还从样本县的备份数据库中获取了2005-2008年参合农民在不同级别医疗机构就诊的费用信息,为本研究系统开发中的模拟试验提供样本数据。(三)分析方法本研究所用分析方法如下：1.文献归纳法。对收集的文献及政策文件等二手资料进行归纳和总结。2.定量资料分析方法机构调查资料用Microsoft office Excel 2003软件录入数据建立各县数据库,对各县数据库源进行数据清理、数据集成、数据转换操作后,作为输入文件导入新农合筹资信息辅助决策软件进行统计分析。3.定性资料分析方法将访谈和现场调研的记录内容进行分类整理和记录,寻找各个不同个案中的共性,或直接引用典型个案资料。4.多因素回归分析采用非条件Logistic回归对影响新农合补偿受益的因素进行分析。5.软件工程开发方法本文在设计开发辅助决策软件的过程中按照经典软件工程学的开发流程完成,依次按照需求分析、设计、编程、测试和维护等阶段完成。6.医疗保险费的测算方法通过医疗保险费的测算方法,测算不同补偿方案下新农合基金的使用情况,为调整样本县新农合制度提供参考依据。四、研究结果(一)样本县(市)新农合管理信息系统的发展状况通过2006年和2008年两次对六样本县(市)新农合管理信息系统的调查,作者发现六县(市)新农合管理信息系统发展水平不均衡,但均有一定提高。网络建设及技术支撑方面,山东省由于经济发展情况更好,其三县的信息化发展平均水平好于宁夏回族自治区的三个县。其中山东省章丘县和东阿县以及宁夏回族自治区的中宁县实现了网络版软件；山东省昌乐县和宁夏回族自治区的永宁县实现了单机版业务平台,永宁县仅仅实现了Excel软件数据报表业务；宁夏回族自治区的青铜峡市仍使用手工业务处理。信息化建设资金方面,六样本县(市)中山东三县2005年开始筹建新农合管理信息系统,信息化建设费用由财政拨款,较为充足。宁夏三县得到的财政拨款较少,但目前正筹划由宁夏自治区卫生厅建立一个整合各卫生系统的信息平台,包括合作医疗、传染病网络直报等。在人员配备上,信息化建设较好的山东三县及宁夏的中宁县均配备了1-2名专职人员负责信息化相关工作,但专业素质有待于提高。(二)样本县(市)新农合管理信息系统存在的问题信息化把新农合管理人员从繁重的手工操作中解放出来,提高了工作效率但近几年,新农合管理信息系统运行过程中也暴露出一些问题。一是在硬件建设方面,各地县级业务系统建设发展不均衡,水平差异大。二是技术上仍然停留在信息的收集和汇总上,尚不具备对已有信息的深度分析能力,为各地决策层提供决策支持的水平有限,具体表现在：补偿方案测算困难,存在资金沉积现象；系统设计不够灵活；缺少对参合群体的分析；缺少监测评价功能；监督和管理水平有待提高。在软件开发管理方面,数据集成困难,数据质量不高。三是组织方面,人员数量不足,专业素质不高。(三)新农合信息决策支持系统的分析与设计根据新农合管理信息系统存在的问题和面临的挑战,本文设计了新农合信息决策支持系统。新农合信息决策支持系统是在新农合管理信息系统的基础上,由数据仓库、数据仓库管理模块、数据挖掘工具、知识分析模块、人机交互模块、决策支持模块组成的。其中,数据仓库管理模块完成了数据仓库的定义,数据的采集、综合、提取等各种操作。数据挖掘工具用于完成决策问题中的各种查询、数据分析和数据开采等。知识发现模块控制并管理知识发现过程,将数据的输入和知识库中的信息用于驱动数据选择过程、知识发现引擎和发现的评价过程。决策支持模块根据实际需求设计需要完成的决策任务。人机交互模块通过自然语言处理和语义查询在用户和系统之间提供相互联系的界面。在本文中,作者设计了新农合管理决策的六个支持模块,即基金运行监测、筹资补偿方案测算、疾病分布监测、参合群体分类分析、新农合监督管理、综合评价。在设计实现的过程中,本文实现了决策支持中的共性部分形成了基础框架。对于与应用领域有密切关系的其它部分则可根据具体的需要在决策支持系统上进行扩展。(四)新农合筹资补偿系统的设计与应用在世界卫生组织的协助下,作者设计并开发了符合中国新农合实际需要的筹资补偿决策系统SimIns。该软件的设计流程为：1)从新农合管理信息系统数据库,医院HIS系统数据库,卫生部门、财政、民政部门收集新农合基金运行、卫生服务相关数据,按照数据的主题域和时间序列进行集成,形成数据仓库,作为SimIns系统的输入。2)选择影响新农合基金使用率和参合农民受益率的主要影响因素,设计新农合筹资补偿方案的调整模式。3)开发人机交互界面,采用多种人机交互手段,包括图表、提示语、窗口界面等,使用户更好地理解测算结果。4)基于筹资补偿决策软件SimIns,以山东省东阿县为例,利用该县2005-2008年的历史数据,对2009年的筹资补偿方案进行了测算,通过改变补偿类型、降低方案中的起付线、提高最高支付限额、提高补偿比例、合并费用分段等手段,调整东阿县现有方案。提供多个可选的调整组合,并对这些可选的方案进行的比较和筛选,最终根据政策背景和实际需求推荐了东阿县的筹资补偿方案,以供新农合管理人员决策选择。五、政策建议第一,各级政府应加大对新农合信息化建设的支持。各级政府应切实承担起对新农合信息化建设提供资金支持的责任,尤其是省级财政和中央财政应及时、足额地给予各县(市)财政支持,以保障新农合信息化建设持续、有效的开展。第二,加强新农合管理机构自身能力建设。各级卫生部门应增加对新农合管理机构的投入,将合管办的办公经费列入财政预算,配备必要的计算机设备和网络设备,增加人员编制,以保证新农合日常工作的顺利进行。同时,合管办工作人员应该加强对医疗保险知识和信息管理知识的学习,提高自身专业能力。第三,建立完善新农合决策支持系统。一是要对新农合管理信息系统中的数据进行数据清洗、数据变换、数据集成、数据装入和建立模型,为信息辅助决策平台提供良好的数据基础；二是结合对卫生政策及新农合基金业务的理解,设计分析模型,提高深度分析和数据挖掘的能力,并开发相应的支持工具,三是设计合理、高效、易用的人机交互系统,从而有效地发挥新农合管理信息系统在筹资补偿、风险预警等方面的管理功能。第四,重视数据质量。数据的准确性、及时性、完整性、一致性和规整性,将直接关系到辅助决策结果的准确性和有效性,关系到新农合管理信息系统在辅助决策、提高财政资金利用率方面的支持作用。为此,应建立完善、规范的管理制度,针对新农合管理信息系统操作流程中的每个环节,规定许可的操作范围和权限,保证操作的规范性,尽可能减少人工操作对数据质量的影响。第五,规范系统接口设计,为系统整合做好准备。正在建设或尚未建设新农合管理信息系统的各县应重视接口设计,严格按照国家规定的标准进行建设。已建设完成的系统应在考虑节约成本的前提下,利用已有系统,通过结构调整、集成中间件转换等技术,最终达到国家标准的要求。第六,提高新农合信息决策支持系统的应用水平。根据决策支持系统的应用效果,扩大决策支持系统的应用领域,提高应用系统的应用水平,使新农合决策系统发挥更大的作用。第七,科学调整筹资与补偿制度,提高受益程度。新农合管理机构可根据当年筹集的基金总额逐步调整补偿方案,优先提高乡镇及县级医疗机构的补偿水平,并通过不同医疗机构费用补偿上的差别,用经济杠杆来引导参合者合理利用卫生资源。更多还原

【Abstract】 [Background]China New Rural Cooperative Medical Scheme (NCMS) is organized and supported by the government of China; in order to relieve rural residents’burdens of disease. Farmers could participate in NCMS voluntarily. As the insured farmer more and more, covering a wide range, the management of NCMS becomes complex now. Handwork could not meet the demand of NCMS. Thus, with the support of different levels of government, NCMS information system based on computer technology, database, and network build up.Information technology is an effective method to improve working efficiency, ensure the security and realize the scientific management of the NCMS fund. With effort of the central government and the local government in the past few years, the NCMS information system has rapidly developed. However, as technology developed, some issues appeared at the same time, as the allocation of the resources is not balanced; duplication of development exists; the function of support decision-making is not full used; the staff is not professional; the management is not standardized, etc.Previous studies on NCMS information systems were less concerning the system support of decision-making. The research related to the improvement of NCMS information system was less reported. Therefore, in order to improve the NCMS information system, this study choose NCMS piloted counties as objects, tries to design the decision-making support system of NCMS. This study make the financing and payment system of NCMS as an example, design and implement the SimIns software to analysis and revise the financing and payment scheme in Dong’e county. It provides evidence for improving financing and payment in NCMS and promoting the development of NCMS.[Objectives]The aim of this study is to design the NCMS decision-making support system, which may provide evidence for improving the NCMS information system and promoting the development of NCMS. Detailed objectives are as follows.1. Find out problems in NCMS information systems. Propose the decision-making support system which suits to China’s actual situation in NCMS. Provide the suggestions to improve the NCMS information system.2. Design and implement the decision-making software SimIns, to support designing and revising the financing and payment scheme in NCMS.3. Explore determinants and influencing factors of NCMS financing and payment scheme. Design a revised financing and payment scheme by using decision-making tool SimIns, and provide political suggestions for NCMS improvement.[Methodology]Data sourcesThere are two parts of data sources in this research, existing data arid survey data. Data collected from survey is mainly used to analysis the status of NCMS information management and simulate the financing and payment scheme of NCMS.Existing data include①the operation and policy documents of NCMS office in pilot counties from 2005 to 2008;②the annual reports of Shandong province in pilot counties from 2004 to 2008;③the household survey results of EU-funded project "China and Vietnam to establish a fair and sustainable rural health insurance" in 2008;④the literature.Survey data include,①the social, economic and demographic development of research counties from 2005 to 2008;②the compensation package of NCMS in research counties;③the interview and survey with the managers of NCMS and governors in research counties;④the management information platform database files in research counties from 2005 to 2008. Data collectionTwo large-scaled field investigations were conducted in 2006 and 2008. Data were collected in four ways as follows.1. Household Survey. According to geographic and economic situation, two provinces Shandong and Ningxia were chosen. Then, three counties were selected from each province in accordance with economic situation. As a result, Zhangqiu, Changle and Dong’e were chosen in Shandong, Qingtongxia, Yongning and Zhongning were chosen in Ningxia. To know about health demand and utilization, NCMS reimbursement and attitude towards NCMS among rural residents, household surveys were conducted in 2006 and 2008, with sample size as 6147 and 3288 households respectively.2 Interview. To know about the implementation, problems in NCMS and stakeholders’attitudes, key-informant interviews and focus-group interviews were conducted.3. Institution investigation. Firstly, learn the administration of NCMS. A questionnaire was designed by researchers and filled out by NCMS officials in NCMS administration to know about the implementation of NCMS. Meanwhile, database related to inpatient reimbursement were provided either. Secondly, learn the situations of healthcare providers. A questionnaire was designed by researchers and filled out by healthcare providers to know about their revenue and expenditure and subsidies from NCMS.Analysis Methods1. Analysis tool. Data from institutions were input and analyzed by Excel 2003. NCMS inpatient reimbursement database were analyzed through SPSS 11.5. Interviews were recorded with informant consent and analyzed by Maxqda2. Data concerning household survey were double input to Epi Data 2.1 and analyzed by SPSS 11.5.2. Premium calculation. Calculate NCMS premium in different benefit packages.3. Logic regression analysis. Calculate the NCMS insurance factors by using logic regression analysis. 4. References reviews. Summarizing second hand materials collected.5. Software development process. The process includes requirement analysis, design, coding, testing and maintenance.6. Calculate financing and payment scheme of NCMS.[Results]Results of this study are as follows.1. The status quo of NCMS information system implementationAccording to the investigation results in 2006 and 2008, the author finds that NCMS information system implemented not balance but smoothly in six sampled counties. Due to the finance reason, the network construction and hardware in Shandong province developed better than in Ningxia province. The Zhangqiu County from Shandong province, as well as the Zhongning County from Ningxia province developed the network version software of NCMS. The Changle County from Shandong province and, Yongning County from Ningxia province used the PC platform for management. Yongning County just realized the Excel software data reporting services. The Qingtongxia City from Ningxia province still managed the NCMS fund by hand.Shandong province, started to build the NCMS information system in 2005, got the financial allocation more adequate than Ningxia province..The department of health in Ningxia province is now planning to establish and integrate all health information platforms, including the NCMS information system and direct reporting network of infectious diseases. There is one or two full time staff responsible for the information management of NCMS in the three sample counties of Shandong province and Zhongning County. However, the qualities of the staff need to be improved.2. The problems of NCMS information system in pilot countiesInformation technology is an effective method to improve working efficiency, however, as more and more systems used, series of issues appeared. Firstly, the development of haredware in different counties is not balance; there is certain of duplication in allocation of resources. Secondly, the data collected from systems do not make full use of analysis, hard to support the decision-making in NCMS. For example, the financing and payment scheme is hard to calculate; the design of system is not flexible enough; lack of participate group analysis; lack of monitoring and evaluation functions; supervision and management level need to be improved. Thirdly, the quality of data from system is not qualified, provincial information platform is not constructed, affecting the data sharing and supervision.3. The analysis and design of NCMS decision-making support systemAccording to the problems and challenges in NCMS information system, the author designs the decision-making support system of NCMS. The NCMS decision-making support system includes data warehouse, data warehouse management module, data mining tool, knowledge and analysis module, human-computer interaction module, the decision support modules. Data warehouse management module need to complete the definition of the data warehouse, data collection, synthesis, extraction and other maintenance operations. The tool of data mining is used to deal with problems by searching, data analysis and mining. Knowledge discovery module is used to control and manage the process of data selection, knowledge discovery engine and found the evaluation process. Decision support modules were designed according to the actual demands of the task. Human-computer interface used the natural language to process module and the semantic query. The author designed six decision support module, including NCMS fund monitoring, calculate and estimate the financing and payment scheme, monitor the distribution of the diseases, participate group analysis, NCMS evaluation.4. The design and implement of the NCMS financing and payment decision-making systemWith the assistance of the World Health Organization, the authors designed and developed the financing and payment decision-making system Simlns according to the demand of China’s NCMS. The design process as follows:1) Data collected from the database of NCMS information system, database of HIS, data from health government and general government. Integrate data as the input of SimIns software from different source.2) found the key factors which effect the NCMS utilization and the benefit of farmers.3) Develop the human-computer interface using a variety of methods, including charts and windows interface.4) Design and implement the SimIns software to analysis and revise the financing and payment scheme in Dong’e County. It provides evidence for improve financing and payment in NCMS and promote the development of NCMS.[Conclusion and political recommendation]1. Government at all levels should further support the development of NCMS information system. Government especially the central and provincial government should take the responsibility and subsidize NCMS in time and in full amount.2. Intensifying the capacity building in NCMS administration. Health bureau should take overhead expenditure of NCMS office into consideration; add equipment, network and position in NCMS office to ensure routine work. Meanwhile, NCMS administration officials should have more knowledge on health insurance to be more professional in daily work.3. Paying attention to the NCMS information decision-making support system. Firstly, provide the good data quality by data cleaning, transformation, integration, loading and model establishment. Secondly, in the context of health policy and NCMS management, improve and optimize the data mining tool, knowledge discovery technology and risk management in health area.4. Paying attention to the data quality in NCMS information system. Improve the accuracy, timeliness, completeness, consistency and regularity of the data. Therefore, the managers should standardize the management in every process of NCMS. Providing licensed operating range and authority to ensure that the manual operation could minimize the impact of the data quality.5. Specification the interface design of the NCMS system. The systems under construction should pay attention to interface design, in strict accordance with the government standards for construction. Already completed systems should adjust the system to national standard by integration middleware, conversion technologies.6. Improving the application of NCMS decision-support system. The NCMS managers should develop more decision-support systems, and expand the application of the systems, so that the decision-support systems could play a greater role in NCMS information management.7. Rationally adjusting the financing and payment scheme to improve enrollees’ benefits. When adjusting financing scheme, it is suggested that individual contribution to premium should be raised. When adjusting payment scheme, it is supposed to give priority to reimbursement policy in county level hospitals.更多还原