【作者】 崔洪春；

【导师】 姜宝法；

【作者基本信息】 山东大学 ， 流行病与卫生统计学， 2011， 硕士

【摘要】 研究背景新型农村合作医疗(简称新农合)是当前中国农村最主要的医疗保障形式,其对于改善农村地区的医疗状况,提高农民健康水平,保证农民获得基本的医疗服务,减轻农民求医问药的经济负担,缓解因病致贫、因病返贫等具有重要作用,在一定程度上缓解了农民看病难、看病贵的问题,减轻了农民的就医压力。但在新农合的实际运行过程中遇到了许多问题,阻碍了新型农村合作医疗制度的发展,表现在统筹补偿模式上,由于我国各地社会经济、文化差异性等多种因素决定了现阶段新农合医疗补偿模式的多样性。表现在补偿方面的主要问题有：许多县(市)在实施新农合时,因补偿方案制定的不合理,使得起付线设置过高,而封顶线又较低,补偿比例偏小,补偿范围较窄,在很大程度上降低了参合农民的补偿水平和受益面。长此以往,必将会削弱新型农村合作医疗制度对农民的吸引力,影响新型农村合作医疗的可持续性发展。研究采取何种统筹补偿方案,或统筹补偿方案如何稳步调整,使其在保证新农合基金安全运营的前提下,提高基金使用效率,逐步扩大农民的受益面,最大程度的满足农民群众的医疗需求,是我们亟待解决的问题。因此有必要收集各种现有统筹补偿方案的研究证据,对现有的统筹补偿方案做出系统综述,并对部分地区新型农村合作医疗统筹补偿方案进行分析,探讨存在问题,提出相应的政策建议,从而为决策者提供高质量的决策依据。研究目的1.收集关于我国新型农村合作医疗统筹补偿方案(补偿模式、起伏线、封顶线、补偿比例、补偿范围)的各类相关文献,以进行分析评价。2.对各种统筹模式进行分析比较,找出最适合我国新农合持续发展的补偿模式。3.对每一种补偿方案进行系统分析和评价,探讨补偿方案最合适、最科学的结构比例。4.提出新农合可持续发展的建议,为决策机构制定新农合统筹补偿方案提供循证依据。5.对部分省份新型农村合作医疗统筹补偿方案运行状况进行分析,探讨其存在问题并提出相应的政策建议。研究方法1.系统综述本研究的方法是参照Cochrane中心关于系统综述的方法和标准,首先根据PICO原则制定检索策略,然后根据制定的文献纳入排除标准检索文献,收集关于新农合统筹补偿方案(统筹模式、起伏线、补偿比例、封顶线、补偿范围)的各类相关文献。将纳入的文献进行质量评价,逐一进行分析,并提取重要信息,最后对文献进行综合分析,然后加以整合,得出结论并提出建议。2.描述性分析本研究第二部分,通过网络搜索部分省份的《2010年新型农村合作医疗统筹补偿方案》,对统筹补偿方案的运行状况进行了描述性分析,指出存在的问题并且提出相应的政策建议。研究结果1.新型农村合作医疗统筹补偿方案研究最终纳入高质量文献70篇,其中44篇文献为2003年至2010年间现况调查研究,有16篇为综述类研究,有10篇为对照研究(分组、前后)；现况调查研究覆盖了我国的大部分地区,其中有19篇主要研究了新型农村合作医疗统筹模式；有32篇文献对新型农村合作医疗的起伏线、补偿比例、封顶线作了单独或综合性的研究,从它们的作用、设置方式、设置大小、设置不合理的影响等多方面进行了阐述；有19篇文献讨论了新型农村合作医疗中医药补偿和慢性病补偿,并对其运行状况和存在的问题进行了研究和分析。根据这些研究证据我们对各种统筹模式进行分析比较,指出住院统筹将是新农合的发展方向；指出如何合理设置起伏线、补偿比例和封顶线能最大程度的提高农民的受益程度；指出要提高中医药的补偿比例,规范慢性病补偿,扩大参合农民的受益面。2.新型农村合作医疗统筹补偿方案运行状况分析本部分研究分析了部分省份现行的统筹模式,并对这些省份的住院补偿方案和门诊补偿方案中的起伏线、封顶线、补偿比例、慢性病补偿进行了相关分析,探讨了补偿方案运行中存在的问题并提出相应的政策建议。结论与建议1.新型农村合作医疗统筹补偿方案研究本部分研究了我国新型农村合作医疗正在运行的三种补偿模式,即大病统筹、住院统筹加门诊统筹、住院统筹加家庭账户模式,对三种补偿模式进行了分析比较,分析比较结果表明：住院统筹加门诊统筹模式将是新农合的发展方向。住院补偿起伏线的设置应按梯形方式设置,随医疗机构级别的增高而增加,起付线大小通常应为同级医疗机构平均门诊费用的2.0-3.0倍比较好；门诊补偿一般不设起伏线。补偿比的设置应按医疗机构级别不同设置不同的补偿比,补偿比应随医疗机构级别的增加而减小,并且应拉大各医疗机构间的差距,分级分层合理分流病人；封顶线的设置应根据当地的经济发展水平和筹资水平而定,原则上不低于当地农民人均纯收入的6倍以下。要尽力扩大补偿范围,提高中医药的补偿比例,规范慢性病补偿,建议将慢性病补偿纳入大病统筹范围,扩大慢性病补偿的种类,合理设置起伏线、封顶线和补偿比,扩大参合农民的受益面。2.新型农村合作医疗统筹补偿方案运行状况分析本部分研究提出要科学制定住院和门诊补偿方案,合理划分基金分配比例,合理设置起伏线、封顶线、补偿比例；规范慢性病补偿,加强基层医疗机构建设。更多还原

【Abstract】 BackgroundThe New Rural Cooperative Medical Scheme(NCMS)is the main medical insurance in current rural China, its for improving rural areas of medical condition, to improve farmers’ health level and ensure farmers obtain basic medical services.reduce the economic burden of fanners medicine doctor. easing the sickness poor, poverty due to illness plays an important role in such relieves farmers difficulties in getting and doctor expensive problem, reduced the farmers medical-seeking pressure. But in the new farming the actual operation process encountered many problems to obstruct the NCMS. especially in the development of overall reimbursement model. Because of our country’s NCMS plan as a whole limits larger (usually county), social,economy and culture differences across various factors determine the present new farming medical compensation mode diversity. Displays in reimbursement of problems are:many of the county (city) in implementing new farm, for reimbursement scheme microroughness unreasonable, making up too high, and paying line set top line and lower proportion of small, compensation, compensation range is narrower, largely reduced the reimbursement ginseng adds up to farmer horizontal and benefited range. In the long run. will weaken the farmers’attraction of the NCMS. influent the NCMS sustainable development.Research what overall reimbursement scheme, or overall reimbursement scheme how to steadily adjustment, make its new farming fund in ensuring safe operation, improve fund under the premise of efficiency, gradually expand the farmers’ benefited range, the greatest degree of satisfaction of peasants needs of medical treatment, is we urgently need to solve the problem. So it is necessary to collect all kinds of existing overall reimbursement plan research evidence to the existing overall compensation plan make system parts were briefly reviewed, and the new rural cooperative medical overall reimbursement schemes are analyzed, existing problems, and puts forward the corresponding policy recommendations for policymakers, thus providing high quality decision-making basis.Objectives1.Collection about the NCMS reimbursement plan (reimbursemen mode, cost sharing ration.limit lin, reimbursemen proportion) with analysis evaluation.2.To all sorts of overall pattern carries on the analysis comparison, to identify the most suitable for China’s new farming and continuous development of compensation mode.3. For every kind of compensation schemes system analysis and evaluation, this paper discusses the most appropriate compensation scheme, the most scientific structure proportion.4. Puts forward new farming sustainable development Suggestions for decision-making agency to develop new farming overall compensation scheme provides evidence-based basis.5.In some provinces of the new rural cooperative medical overall compensation plan operational status analysis, discusses the existing problems and puts forward relevant policy SuggestionsMethods1. Systematic ReviewThis research method is to consult the Cochrane center about system review methods and standards, first of all. according to the principle of PICO formulated according to retrieval strategy formulated, then the were included in the exclusion standard retrieval literature, collect about new farming overall compensation plan (as a whole mode, undulating lines, compensation scale, a top line, compensation range of related literatures.) Will be included in the literature quality evaluation, analysis, and extracted one important information, finally to literature analysis, and then be integrated, draw the conclusion and puts forward some Suggestions.2. descriptive analysisThe second part of zhis study, through the network search some provinces of 2010 the reimbursement plan of NCMS, descriptive analysis the operational status of the reimbursement plan, points out the existing problems and puts forward some corresponding Suggestions.Results1. The study on reimbursement plan of NCMSFinally we include 67 articles,59 of the which are Oinvestigation and study status in2003 to 2010, for such research In current research covers most of the region, there are 17 articles mainly studies the reimbursement modle; 31 references to the cost sharing ration of medical treatment of new-style country collaboration line. compensation scale, the limit line alone or comprehensive research, from their role, set mode, set sizes, the influence of set unreasonable were expounded; 19 references discussed the NCMS reimbursement range of basic drugs directory, the Chinese medicine compensation and chronic compensation for its operation, and the situation and existing problems of the research and analysis. According to the research evidence of various overall pattern we carries on the analysis comparison, points out that hospital as a whole will be new farming development direction:Points out how to setting up reasonable the cost sharing ration, compensation proportion and limit line can maximum degree of improving farmers’benefit levels:Points out that we should reasonable establishing basic drugs, improve the directory, regulating the TCM compensation proportion, expand chronic compensation ginseng adds up to farmers’ benefited range. 2. The new rural cooperative medical overall compensation plan operation condition analysisThis section research and analysis the reimbursement modle of some provinces, and the overall pattern of these provinces hospital compensation scheme and outpatient service compensation plan of the cost sharing ration, limit line, compensation proportion, chronic compensation the correlation analysis, discusses the problems in the operation of the compensation plan problems and puts forward relevant policy Suggestions.Conclusions and Suggestions1. The study on reimbursement plan of NCMSThis section studied the new rural medical cooperative running three compensation mode, namely the poverty-stricken population overall outpatient, hospital, hospital as a whole with overall to add family account, three kinds of compensation mode are analyzed and compared, analysis and comparison results show that:the hospital as a whole will be added outpatient service as a whole new farming the development direction. Hospital compensation thread arrangement should press rolling with trapezoid mode set the increased level of medical institutions, start to pay increase the size usually should line of medical institution of average outpatient fee 2.0 to 3.0 times better; Outpatient service compensation generally do not set ups and downs line. Compensation according to the set than medical institution shall be different sets of different compensation levels than, than with medical institutions shall compensate the increased level of decreased and the medical institutions shall be widened the gap between the reasonable divergence patients, grading stratification; Top line Settings should according to local economic development level and funding level and decide, in principle of local per capita net income of farmers not less than 6 times of the following. Try to expand sphere of compensation, improve the compensation of traditional Chinese medicine, regulating the chronic compensation, proportion of species, expand chronic compensation reasonable set ups and downs line, a top line and compensation than, expand ginseng adds up to farmer benefited range.2. The study on operationl status of NCMSThis section study proposed to science formulation reimbursement scheme. rationally divided fund allocation proportion, setting up reasonable cost sharing ration. limit line, reimbursement proportion; Standard chronic compensation, strengthen construction of basic-level medical institutions.更多还原