新型农村合作医疗制度下患者分流机制研究

【作者】 田志娟；

【导师】 李斌；

【作者基本信息】 中南大学 ， 社会学， 2011， 硕士

【摘要】 新型农村合作医疗制度(以下简称“新农合”)是由政府组织、引导、支持,农民自愿参加,个人、集体和政府多方筹资,以大病统筹为主的农民医疗互助共济制度。我国实施这一政策的根本目的是为了缓解农民医疗负担,解决农民“因病致贫、因病返贫”的问题,根本目的的实现离不开一系列具体目标,本文所研究的患者分流便是其中之一。新农合想要实现的是患者分流逻辑从取决于经济能力转变为取决于疾病严重程度,以达到合理分流。通过相关的统计数据,我们发现新农合制度实施以来,农民患者的现实分流逻辑没有转变为疾病严重程度,基于相关理论分析和前人的研究,本文建立了-个新农合制度下农民患者分流机制的模型图,此模型是新农合制度、医疗机构和参合农民三者在农村医疗卫生服务系统层面的复合体,笔者认为这三者自身的特征以及相互作用造就了现实的患者分流。在理论分析的基础上,本文以湖南省中方县为例,从新农合制度、医疗机构和参合农民三个维度对新农合制度下患者分流机制进行了实证研究,获得以下发现：(1)新农合实施以来,在意识和认知上,农民患者分流的逻辑基本实现了由取决于经济能力向取决于疾病严重程度的转变,但由于新农合制度执行不力、监管不严等原因,医疗机构能够规避制度规定从事不规范诊疗行为,参合农民没有得到真正实惠,致使农民患者的现实分流逻辑没有转变,在基层医疗机构就诊的人数不但没有增多,反而有减少的趋势,经济能力仍然是制约农民选择就医机构的重要因素。(2)我国农村医疗服务体系不完善,各级医疗机构没有各司其职,这制约着农民患者的合理分流。(3)患者分流与医疗机构的诊疗行为有关,求利性的诊疗行为使患者分流依赖于经济能力,公益性的诊疗行为使患者分流依赖于疾病严重程度。在市场经济的影响下,我国医疗机构的诊疗行为具有显著的求利性,这也制约着农民患者的合理分流。(4)年龄和文化程度对农民患者分流没有显著影响,就社会经济水平而言,其对患感冒之类的小病和中等程度疾病人群的分流影响不明显,但当患重大疾病时,经济能力是影响患者分流的主要因素。患者合理分流有利于各级医疗机构医疗资源得到充分利用,也有利于患者得到有效的、经济的治疗,使每一份医疗资源发挥最大的功效,新农合政策应不断完善其各项制度,并联合医疗机构和农民,发挥分流机制对患者分流的导向作用,使患者分流逻辑真正实现向疾病严重程度转变,最终解决农村居民就医难的问题。更多还原

【Abstract】 The new type of rural cooperative medical care system (hereinafter referred to as NCMS) is farmers medical help each other in all aid system with the focus on comprehensive arrangement for serious disease. It is organized, guided, supported by government and receives multilateral financing from individuals, collective, and government. The fundamental aim for our country to carry this policy out is to relief farmers’ medical burden; solve the farmers’ problem of "become poor because of illness, return to poverty due to illness". The realization of such aim can’t be done without a series of specific goals. This paper studies one of the specific goals which is transition of patients shunt logic. The NCMS aims to make the patients shunt logic switch from economic-ability-dependent mode to severity-of-illness-dependent mode and finally achieve reasonable shunt.According to the relevant statistical data, this paper found:the rural patients shunt logic in reality hasn’t switched to severity-of-illness-dependent mode since the implementation of the NCMS. Based on related theory analysis and former studies, this paper established a model diagram for mechanism of farmer patients shunt in NCMS. This model diagram is complex of rural health service system with three main parts:NCMS, medical institutions, farmers participated in NCMS. The interior characters of the three parts and their interaction contribute to the present rural patients shunt logic.This research takes Zhongfang County of Hunan province as an example to empirically study the mechanism of patient shunt under NCMS on the ground of theoretical analysis, and discusses in three dimensions:NCMS, medical institutions, farmers participated in NCMS. Findings:(1) Since the application of NCMS, the farmer patients’ shunt logic basically switched from economic-ability-dependent to severity-of-illness-dependent in terms of ideology and cognition. But due to weak implementation and lax oversight of the NCMS, medical institutions could escape the system and engage in acts of non-standard treatment, resulting in farmers do not gain real benefits, with view to concrete action, this kind of switch is not obvious. Not only the number of people who see doctor in basic-level medical institution did not increase, but there is a trend of decrease. Economic ability still is an important factor that restricts farmers’ choice of medical institution. (2)In our country, the rural medical service system isn’t consummate, and medical institutions of all levers don’t perform their duties, which restrict the reasonable shunt of the patients. (3) The patients shunt is related to the diagnosis and treatment of the medical institutions. Diagnosis and treatments for profit make patients more on economic ability, while diagnosis and treatments for public interest lead patients to count more on the severity of illness. In the market economy, the diagnosis and treatments of the medical institutions have significant demands for profits, which also restrict the reasonable shunt of the patients. (4) Age or education has no significant effect on the patient shunt. As to social economic level, it has little effect on the patient shunt of the patients with minor illness moderate illness. But economic ability becomes the major factor when encounter some severe illness.The reasonable shunt of the patients is beneficial for making full use of the medical resources in medical institution at all levels, and it can also help patients get effective and economical treatment. NCMS should be modified in terms of its policies. It also should work together with medical institutions and farmers to give play to their common guidance to patient shunt so that the logic of patient shunt change to severity-of-illness-dependant for real and finally solve the difficult problem of rural residents in seeing a doctor.更多还原