【作者】 白毅；

【导师】 孙振球；

【作者基本信息】 中南大学 ， 社会医学与卫生事业管理， 2010， 博士

【摘要】 目的：通过对国内外有关医保政策和措施的研究,运用卫生统计学和卫生经济学的方法对2002年4月1日-2006年12月31日湖南省医保长沙市参保职工的住院疾病谱和住院费用进行分析,并探讨其影响因素,以期为医疗保险制度的进一步改革和完善提供科学依据。方法：从湖南省医疗保险基金管理服务中心医疗保险管理信息系统中,抽取2002年4月1日-2006年12月31日参保职工且在此期间有出院经历的住院患者。数据清理后得到符合研究要求的参保人员102828例,构成本研究的总体。本研究的研究单位“例”为出院人次,如果同一个人多次住院,计为不同人次。按照出院年份,采用分层随机抽样的方法,抽得参保人员共8550例,构成本研究样本。本研究按ICD-10疾病分类标准,从分析样本的疾病构成出发,探讨了省医保长沙市参保职工的住院疾病谱并从不同性别、不同年龄分组、不同工作状况、不同单位性质、不同级别医院、不同年份、不同病种等方面进行次均住院费用单因素分析；以次均住院费用为应变量,以性别、年龄分组、工作状况、单位隶属、医院级别、年份、疗效、手术情况、住院天数以及ICD-10病种分类为自变量进行逐步多元线性回归分析；按出院年度分组,按ICD-10大类分组,按医院等级分组进行住院费用统筹与自付比例描述行分析；以性别、年龄、公务员级别等可能的影响因素为分组变量,以自付比例为反应变量进行自付比例单因素分析；以自付比例为应变量,以性别、年龄分组、公务员级别、工作状况、单位性质、单位隶属、医院级别、年份、手术情况、是否大病以及住院天数为自变量,进行逐步多元线性回归分析,讨论自付比例的主要影响因素；采用数据包络分析法评价医保效率；以省医保2002-2006年总体资料为依据对其次均费用进行灰色预测；采用路径分析对次均费用影响因素进行探讨。本研究采用描述性统计分析,单因素分析,灰色预测,数据包络分析,路径分析等方法进行统计分析和卫生经济学评价。所采用统计分析软件包括：Excel 2003、SPSS15.0、SAS9.13和Matlab6.5。结果：1.住院疾病谱分析：循环系统疾病、呼吸系统疾病、肿瘤、消化系统疾病、泌尿生殖系统疾病等慢性病是医保住院患者疾病构成最高的五种疾病。男性不同年龄分组疾病构成分析显示,循环系统疾病、呼吸系统疾病、消化系统疾病是男性各年龄组的主要疾病。消化系统疾病是45岁以下男性的主要疾病,占27.5%,循环系统疾病是45-59岁和59岁以上男性的主要疾病,占分别占21.8%和33.9%。女性各年龄组中,循环系统疾病、泌尿生殖系统疾病、消化系统疾病、肿瘤是主要疾病。其中,泌尿生殖系统疾病是45岁以下女性的主要疾病,占25.7%,循环系统疾病是45-59岁和59岁以上女性的主要疾病,分别占19.1%和38.0%。消化系统疾病和肿瘤两大疾病在三个年龄分组中分别位于第二位和第三位。2.住院费用分析：不同性别的住院患者的次均总费用、监护费、治疗费、药品费和一般医疗服务费的差异均有统计学意义(P<0.05),各项费用基本为男性患者高于女性患者。而检查化验费和材料费在男女患者间差别无统计学意义；不同年龄分组的住院患者的次均总费用、监护费、检查化验费、治疗费、材料费、药品费和一般医疗服务费的差异均有统计学意义(P<0.05),两两比较提示,各项费用基本为大于59岁年龄组花费最高；在不同工作状况分组的住院患者间,次均总费用、监护费、检查化验费、治疗费、药品费和一般医疗服务费的差异均有统计学意义(P<0.05),各项费用基本为退休患者花费大于在职。而材料费在在职和退休患者间差别无统计学意义；不同单位性质分组的住院患者的检查化验费、治疗费、材料费和药品费的差异均有统计学意义(P<0.05)。而次均总费用、监护费和一般医疗服务费在企业、事业和行政单位患者间差别无统计学意义；不同级别医院间,各项费用基本均为三级医院最高,二级医院次之,一级医院最低；在不同年份分组的住院患者间,次均总费用、监护费、检查化验费、治疗费、材料费、药品费和一般医疗服务费的差异均有统计学意义(P<0.05),总的来看,各部分住院费用呈逐年增加趋势；ICD-10各大类住院人次构成前5类疾病为循环系统疾病(25.50%),消化系统疾病(15.02%),肿瘤(11.10%),呼吸系统疾病(10.95%),泌尿生殖系统疾病(9.22%)；住院总费用最高的前5类疾病为循环系统疾病,肿瘤,消化系统疾病,呼吸系统疾病,泌尿生殖系统疾病,不同年度不同疾病的住院总费用排序略有波动,但这5类疾病均排在前五位；次均费用最高的5类疾病依次是肿瘤,血液及造血器官疾病,影响健康状态和与保健机构接触的因素,神经系统疾病,内分泌、营养和代谢疾病。次均费用最低的5类疾病依次是皮肤和皮下组织疾病,疾病和死亡的外因,呼吸系统疾病,泌尿生殖系统疾病,先天性畸形、变性和染色体异常；消化系统疾病、肿瘤、泌尿生殖系统疾病和循环系统疾病是各年龄分组人群住院费用最高的五种疾病所共有的四种疾病,肌肉骨骼系统和结缔组织疾病是中年人群(45-59岁)的主要疾病；住院费用较高的病种与住院费用较低的病种相比,药费所占比重更大,而手术费、材料费所占比重较低；其余各因素次均住院费用比较显示,单位隶属、疗效、手术情况、住院天数的差异有统计学意义；采用逐步多元线性回归对住院费用进行多因素分析,结果表明除工作状况、单位隶属和疗效外,其余7个因素：性别、年龄分组、医院级别、年份、ICD-10病种、手术情况和住院天数均是次均住院费用的主要影响因素。3.住院费用自付比例分析：各年度统筹与自付比例的差异无统计学意义；按ICD-10分类标准,次均自付比例最高的五类疾病分别是妊娠、分娩和产褥期疾病(46.54%),眼和附器疾病(44.90%),先天性畸形、变性和染色体异常(43.55%),耳和乳突疾病(35.90%),疾病和死亡的外因(34.58%)。最低的三类疾病是呼吸系统疾病(27.91%),血液及造血器官疾病(26.71%),神经系统疾病(26.49%)。次均自付费用最高的五类疾病是肿瘤(2691.36元),血液及造血器官疾病(2570.21元),妊娠、分娩和产褥期疾病(2568.78元),先天性畸形、变性和染色体异常(2240.19元),症状、体征和临床与实验室异常(2174.30元)。统筹总支付费用最高的五类疾病分别是循环系统疾病(1211.45万元),肿瘤(680.92万元),消化系统疾病(581.92万元),呼吸系统疾病(363.18万元),泌尿生殖系统疾病(309.84万元)；一级医院患者费用的自付比例22.32%,二级医院自付比例为24.33%,三级医院自付比例为32.40%,医院等级越高自付比例越高；逐步多元线性回归结果显示,性别、年龄分组、公务员级别、工作状况、单位性质、单位隶属、医院级别、年份、手术情况、是否大病、住院天数均是自付比例的主要影响因素。4.数据包络分析结果表明：F矩阵得出决策单元1、3、4、5的相对有效值等于1,为弱DEA (Output-C2R)有效,决策单元2为非弱DEA (Output-C2R)有效。R矩阵得出决策单元1、3、4、5为规模收益不变,决策单元2为规模收益递增。Rr矩阵得出决策单元1、2、3、4、5没有呈现出弱拥挤现象,决策单元1、3、4、5在给定投入下的产出是最大的,决策单元2的规模收益是递增的,这五个决策单元不会出现输入减少,输出反而增加的现象。说明2002年-2006年,除2003年外,省医保的投入都有较好的产出效果,为进一步提高投入效率,应把各挂钩医院对住院病人的治愈率和好转率纳入考核指标体系。5.经灰色预测结果显示,以2002年-2006年的发展趋势可以预测长沙市省医保参保职工的次均住院费用从2006年开始逐年下降,提示医保工作成效显现,医保费用支出将在更高的水平上得到一定的缓解。6.路径分析表明,有两条显著的影响次均费用的路径。一为住院天数→次均费用；二为出院诊断、医院级别、年龄、性别、是否手术、单位性质→次均费用,而其中的可控性因素为通过减少住院天数来降低住院费用及自付比例。结论1.不同性别、不同年龄组医保住院患者疾病构成有共同点也有差异。循环系统疾病、呼吸系统疾病、肿瘤、消化系统疾病、泌尿生殖系统疾病等慢性病是医保住院患者的主要疾病,但是构成存在差异。2.不同性别、不同年龄分组、不同工作状况、不同单位性质、不同级别医院、不同年份、不同病种分组的住院患者是住院费用的影响因素。3.住院总费用最高、住院人次最多及统筹支付费用最高的三类疾病均为循环系统疾病,肿瘤,消化系统疾病。性别、年龄分组、医院级别、年份、ICD-10病种、手术情况和住院天数均是次均住院费用的主要影响因素,住院天数越长,医院级别越高,年龄越大,住院费用越高的疾病次均住院费用越高,手术要比非手术的次均费用高,男性次均费用高于女性,且次均费用呈逐年增高趋势。4.药费所占住院费用比重大,最高的肿瘤疾病药品费占到57.92%。5.自付比例最高的五类疾病分别是妊娠、分娩和产褥期疾病,眼和附器疾病,先天性畸形、变性和染色体异常,耳和乳突疾病,疾病和死亡的外因。医院等级越高自付比例越高。6.数据包络分析结果说明除2003年外,2002年-2006年省医保的投入都有较好的产出效果；根据2002年-2006年的发展趋势对次均费用进行灰色预测,发现其从2006年开始稳中有降,结果说明医保工作取得了成效；通过路径分析得出了影响次均费用的两条显著路径,一为住院天数→次均费用；二为出院诊断、医院级别、年龄、性别、是否手术、单位性质→次均费用,而其中的可控性因素为,在保证医疗质量的前提下减少无效住院天数来降低住院费用及自付比例,这是控制住院总费用的关键。更多还原

【Abstract】 Objective:Through the study of domestic and foreign medical insurance policies and measures, we analyzed the hospitalization disease records and expenditures of medical insured government employees and workers (MIGEW) in Changsha city from April 1,2002 to December 31, 2006 with the theory of health statistics and health economics in order to probe its affected factors and provide scientific data to further reform and improve the medical insurance system.Methods:The samples of in-patients of MIGEW from April 1,2002 to December 31,2006 were drawn out from the data of Hunan Provincial Medical Insurance Fund Center (HMIFC),102,828 patients were selected as the study population after strict data checking and screening. The "case" was the study unit which meant person-time of patients who left hospitals. If the same patient lived in hospital many times, it will be counted for different person-times. With the method of stratified random sampling, 8,550 cases were drawn out to compose the study samples from the MIGEW population according to the years of patients left hospitals.According to ICD-10 diseases classified standards and analyzed samples of diseases composition, we carried out the person-time hospitalization expenditure univariate analyses of different sexes, age groups, work statues, unit sorts, hospital grades, years and disease types. The analyses of gradual multivariate linear regressions were done based on dependent variable of person-time hospitalization expenditures and independent variable of sexes, age groups, work statues, unit sorts, hospital grades, years, treatment effects, operations, hospitalization days as well as ICD-10 disease categories. The descriptive analyses were done based on government-paid and out of pocket proportions in accordance with yearly groups of patients out of hospitals, ICD-10 disease categories and hospital grades. The out of pocket proportion univariate analyses were done based on sexes, ages, officials at different levels and other possible factors as grouped variables, and out of pocket proportion as dependent variables. The analyses of gradual multivariate linear regressions were done based on out of pocket proportion as dependent variable, and sexes, age groups, officials at different levels, work statues, unit sorts, subordinative units, hospital grades, years, operations, if or not serious diseases and hospitalization days as independent variables in order to discuss the main affected factors of out of pocket proportion. The data envelopment analysis was applied for evaluating medicare efficiency, the gray forecast was used for analyzing the population data of per-time average expenditures from 2002 to 2006, and the path analysis was used for discussing the affected factors of per-time average expenditures.The study was analyzed and evaluated by statistic analyses and health economic evaluations, including descriptive statistic analysis, univariate analysis, gray forecast, data envelopment analysis, path analysis and so on. The analytic software used in the study including Excel 2003, SPSS 15.0, SAS9.13 and Matlab6.5.Results:1. Analysis of hospitalization disease category. The chronic diseases of circulatory system, respiratory system, tumor, digestive system and urogenital system were the top 5 diseases of medical insured in-patients. The disease composition of different male age groups showed that circulatory system, respiratory system, digestive system diseases were the main diseases of every male age group. Digestive system disease was the main disease of the male ages below 45, accounted for 27.5%. Circulatory system disease was the main disease of the male ages from 45 to 59 and 59 above, accounted for 21.8% and 33.9% respectively. The diseases of circulatory system, urogenital system, digestive system and tumor were the main diseases of every female age group. Among them, urogenital system disease was the main disease of the female ages below 45, accounted for 25.7%, circulatory system disease was the main disease of the male ages from 45 to 59 and 59 above, accounted for 19.1% and 38.0% respectively. The two big diseases of digestive system and tumor became the second and third diseases in the three age groups.2. Analysis of hospitalization expenditures. All there were statistical significance of the difference of per-time total average hospitalization expenditures, monitoring and nursing fees, treatment costs, drug fees and general medical service charges (P<0.05), basically each expense of males’ was higher than females’. There were no statistical significance of checking and assay fees and material costs between male and female patients. There were statistical significance of the difference of per-time total average hospitalization expenditures, monitoring and nursing fees, checking and assay fees, treatment costs, drug fees and general medical service charges (P<0.05) in different groups of various aged patients. Compared with the two, the results showed that highest cost of every fee basically was 59 years old group. There were statistical significance of the difference of per-time total average hospitalization expenditures, monitoring and nursing fees, checking and assay fees, treatment costs, drug fees and general medical service charges (P<0.05) between different groups of patients in various working statues, and every fee of the retired patients was higher than the patients in service.. There were no statistical significance of the difference between the retired and the patients in service in material costs. There were statistical significance of the difference of checking and assay fees, treatment costs, material costs and drug fees (P<0.05) in different groups of unit sorts. There were no statistical significance of the difference of per-time total average expenditures, monitoring and nursing fees and general medical service charges in corporations, non-business organizations and administrations. Basically, the highest cost of every expenses occurred in three-grade hospital, and second in two-grade hospital, and the lowest in one-grade hospital. There were statistical significance of the difference of per-time total average expenditures, monitoring and nursing fees, checking and assay fees, treatment costs, material costs, drug fees and general medical service charges (P<0.05) between the patients in various groups of years. In general, the tendency of every proportion of hospitalization expenditures went up each year. According to the hospitalization patient-time, the top 5 diseases of ICD-10 disease categories were circulatory system (25.50%), digestive system (15.02%), tumor (11.10%), respiratory system (10.95%) and urogenital system (9.22%). The top 5 diseases of hospitalization expenditures were circulatory system, tumor, digestive system, respiratory system and urogenital system. Although the order of total hospitalization expenditures varied yearly, the five diseases were all in the top 5. The top 5 diseases of per-time average expenditures ordinally were tumor, blood and hematopoietic organ diseases, factors of influencing health statues and contacting with healthcare units, neural system diseases, endocrine diseases, nutrition and metabolism diseases. The lowest 5 diseases of per-time average expenditures ordinally were dermatosis and hypodermic tissue diseases, external factors of diseases and deaths, respiratory system diseases, urogenital system diseases, congenital abnormalities, denaturalization and chromosome abnormities. The four diseases of the digestive system, tumor, urogenital system and circulatory system were the mutual diseases in the top 5 in every age group. The diseases of muscle skeletal system and connective tissues were the main diseases of middle aged people (45-59 years old). Compared with the high and low cost diseases of hospitalization expenditures, drug fees accounted for a big proportion of them, and operation and material fees just accounted for a small proportion of them. Compared with other every factor of hospitalization expenditures, there was statistical significance of the difference of subordinative units, treatment effects, operation effects, hospitalization days. The analysis on hospitalization expenditures with multivariate linear regressions showed that the seven factors such as sexes, age groups, hospital grades, years, ICD-10 disease categories, operations and hospitalization days were the main effective factors except the working statues, subordinative units and treatment effects.3. Out of pocket analysis of hospitalization expenditures. There were no statistical significance of the difference between yearly government-paid and out of pocket. According to the standards of ICD-10 disease categories, the highest five diseases of per-time average self-paid were pregnancy, childbirth and childbed diseases (46.54%), ophthalmic diseases (44.90%), congenital abnormalities, denaturalization and chromosome abnormities (43.55%), ear and papillary diseases (35.90%), external factors of diseases and deaths (34.58%). The lowest three diseases were respiratory system diseases (27.91%), blood and hematopoietic organ diseases (26.71%), neural system diseases (26.49%). The highest five diseases of per-time average out of pocket expenditures were tumor (￥2,691.36), blood and hematopoietic organ diseases (￥2,570.21), pregnancy, childbirth and childbed diseases (￥2,568.78), congenital abnormalities, denaturalization and chromosome abnormities (￥2,240.19), symptoms, somatogenies, clinical and laboratory abnormalities (￥2,174.30). The highest five diseases of government-paid expenditures were circulatory system diseases (￥12,114,500), tumor (￥6,809,200), digestive system diseases (￥5,819,200), respiratory system diseases (￥3,631,800), urogenital system diseases (￥3,098,400). The out of pocket proportion of hospitalization was 22.32% in one-grade hospital, 24.33% in two-grade hospital,32.40% in three-grade hospital, and this meant that the more grades hospital had, the higher expenditures patient paid. The result of multivariate linear regressions showed that the main affected factors of out of pocket proportion were sexes, age groups, official levels, working statues, unit sorts, subordinative units,hospital grades, years, operation effects, if or not suffered serious diseases, hospitalization days.4. The result of data envelopment analysis showed that F matrix got the relative virtual value of decision-making unit 1,3,4,5 equal to 1, it was effective as weak DEA (Output-C2R), decision-making unit 2 was effective as non-weak DEA (Output-C2R). R matrix got no changes of the scale incomes of decision-making unit 1,3,4,5, the scale incomes of decision-making unit 2 increased step-up. Rr matrix got no weak crowded phenomena of the decision-making unit 1,2,3,4,5, the output of the decision-making unit 1,3,4,5 was the biggest while invested, the scale incomes of decision-making unit 2 increased step-up, and the five decision-making units would not appear the phenomena of input decrease and output increase on contrary. The above-mentioned showed that except 2003 the investment of Hunan Provincial Medical Insurance got a very good output from 2002 to 2006. The cure and recovery rates of patients in medical insurance appointed hospitals should be brought into the evaluation targets so as to further elevate the efficiency of investment.5. The result of grey forecast showed that according to the developed tendency of 2002 to 2006, the per-time average hospitalization expenditures of MIGEW in Changsha were dropped yearly from 2006, and this also reflected the efficiency of medical insurance achievements, and the payout of medical insurance would be declined on a higher level.6. Path analysis showed that there were two obvious paths to influence the per-time average expenditures. One was hospitalization days to per-time average expenditures, the other was out hospital diagnosis, hospital grades, ages, sexes, if or not operations, unite sorts to per-time average expenditures, and among them controllable factors could reduce hospitalization expenditures and out of pocket proportion through shortening hospitalization days.Conclusions:1. There were common and difference of the same diseases in medical insured in-patients of various sexes and age groups. The chronic diseases of circulatory system, respiratory system, tumor, digestive system and urogenital system were the main diseases of medical insured in-patients, but there were differences in patient composition.2. The hospitalization patients of different sexes, age groups, working statues, unit sorts, hospital grades, years and diseases were the affected factors of hospital expenditures.3. The three diseases of the most expensive total hospitalization expenditures, the most population of hospitalization person-time and the highest hospitalization expenses paid by government were circulatory, tumor and digestive system diseases. The main affected factors of per-time average hospitalization expenditures were sexes, age groups, hospital grades, years, ICD-10 diseases, operations and hospitalization days. The per-time average hospitalization expenditures of diseases were higher while the longer the hospitalization days, the higher the hospital grades and ages as well as hospitalization expenditures occurred. The per-time average expenditures of operations were higher than that of non-operations. The per-time average hospitalization expenditures of males were higher than that of females, and the tendency of per-time average hospitalization expenditures went up yearly.4. Drug fees accounted for a big proportion of hospitalization expenditures, the highest drug fee of tumor accounted for 57.92%.5. The top five out of pocket diseases were pregnancy, childbirth and childbed, ophthalmic diseases, congenital abnormalities, denaturalization and chromosome abnormities, ear and papillary diseases, and external factors of diseases and deaths. The higher the grade hospital got, the higher out of pocket proportion resulted in.6. The results of data envelopment analysis showed that except 2003 the output effects invested by Hunan Provincial Medical Insurance from 2002 to 2006 were very good. According to the grey forecast of 2002-2006 developed tendencies, we found that the per-time average expenditures declined stably from 2006, and the result showed that the medical insurance got effects. Path analysis showed that there were two obvious paths to influence the per-time average expenditures. One was hospitalization days to per-time average expenditures, the other was out-hospital diagnosis, hospital grades, ages, sexes, if or not operations, unite sorts to per-time average expenditures. Under the guarantee of medical quality, shortening invalid hospitalization days to reduce hospitalization expenditures and out of pocket proportion is a controllable factor and the key to control total hospitalization expenditures.更多还原