【作者】 杨百团；

【导师】 尹爱田；

【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】 研究背景缺少节制的医疗市场化改革造成了医疗费用的过快上涨,给广大没有基本保障的农民造成了不堪重负的压力。2003年我国重建新农合,对基金分割提出了以大病统筹为主的目标,以收定支、收支平衡的基本要求,公开、公平、公正分配的原则,以及兼顾体检等分割范围的界定。新农合基金的运行过程大致分为筹资、分割、补偿与监管四个阶段,基金分割是该制度从筹资到补偿得以顺畅运行的中间环节。同时,由于筹集的基金总额越来越大,蛋糕做大了,但公平、公正分割蛋糕的机制与规则并没有建立起来,使旧的不公平打破后又出现新的不公平,使弱势群体更趋弱化。在山东省的实际工作中,各县基本每年都要根据筹资、补偿和结余的情况来分析测算当年的基金分割是否合理,来年如何进行调整和改进,但由于有些县的管理人员变动频繁,有时会出现一些没有新农合实践经验的领导来负责决策,或者原来的管理人员对新政策与新情况的疏忽,也难免会造成一些基金分割与使用方面的问题,而一旦运行方案经过审批公示,原则上一年之内不能做大的修改,则容易导致问题的进一步积累加重。由此看来,建立科学合理、适应山东省实际的基金分割与使用机制,对于促进全省各地新农合制度的不断完善,增强管理的质量和时效性,都具有极为重要的理论意义和现实意义。但检索文献后发现国内没有系统研究新农合基金分割理论与模型的报道,少数实证研究主要是关于补偿模式分类、影响因素和大病小病如何界定等问题的局限性研究,在理论上存有分类混乱等多处缺陷,因此需要根据新农合的试点、推进与普及的发展规律,进行一次深入系统的新农合基金分割理论的研究,以期厘定模糊之处,为更好地提高参合农民的受益水平而服务。研究目标本研究的目标主要是从理论与实证方面对山东省的新农合基金分割进行科学探讨,并运用设计的模型进行实证,以求找到科学的分割方法,为今后完善新农合制度提供借鉴和参考。理论方面：以福利经济学理论、社会保障理论、最优资源配置理论、决策理论等经济学和社会学方面的理论为基础,结合我国和山东省的新农合制定的方针政策,探讨建立新农合基金分割的理论,并明确它的内涵外延、确立原则等。实证方面：以山东省2003-2009年的数据为准,分别对各级门诊与住院支出、体检、住院分娩、大病统筹、二次补偿、风险基金和基金结余等方面做分析论证,辅之以实际调查的体验和所获数据,通过纵横比较,揭示目前山东省新农合基金分割方面存在的问题、成因等。模型方面：利用Delphi法为主的方法学,以山东省新农合技术指导专家库的专家意见为基准,建立一个具有适用性和可操作性的山东省新农合基金分割标准,以便各统筹单位可以据此比较方便快捷地调整每年的基金分配,解决盲目决策带来的过度结余与过度超支等影响基金使用效率的问题。并可以利用该模型,验证过往各统筹单位基金分割的效率。最后,提出做好基金分割的政策建议。资料来源与研究方法资料主要来自三个方面,一是参考文献,二是现场调研资料,三是专家咨询资料。根据不同的研究目的,采取了不同的研究方法。对新农合基金分割理论研究采用了文献复习法,演绎推理法等,对新农合基金分割模型研究,采用了改进的德尔菲法,对新农合基金分割实证研究,采用了定性与定量相结合、现场调查与文献资料相结合的方法,对于数值变量资料,使用均数、极差、标准差、变异系数等指标,对于分类变量,用率、构成比、相对比等指标。此外,还运用了比较分析法、分层抽样法、统计模型法等方法。研究结果在理论研究方面,通过对既往政策的研究和借鉴了国内外的部分经济学、社会学方面的理论,在国内首次提出了新农合基金分割的理论、内涵和外延等,并确定了保基本原则、有效性原则、平衡原则、公平性原则、效率性原则、统筹兼顾原则等基本原则。提出在现有基金分割中剔除掉体检基金、住院分娩基金的设置,转由公共卫生专项资金来承担。提出去掉二次补偿基金,改为一次性调整补偿比等方法。在模型研究方面,建立了专家的基金分割“金标准”,推导了数字化的新农合基金分割模型。通过模型可以看出,年度筹资和分级医疗机构的补偿比有动态相关的关系,在部分数值可以估算或既成事实的前提下,能对其他数值进行推算,或者通过调整比例或数额进行微调,从而使政策制定者可以根据本地的实际情况来决定如何设计总体方案。这种模型,可以有效防止拍脑袋决策的弊端。在补偿比设定的前提下,也可以大致推算未来需要筹资的总数,为将来科学筹资服务。也可以将专家汇总意见的比例值直接代入模型,调整某项费用的基金支出。同时,为了模型的可操作性,又根据政策推导出了模型的五项限制条件。在实证研究方面,构想了“大”、“中”、“小”三个模式,从全省角度、不同收入类型县角度和小样本县角度对山东省新农合2003-2009年的基金分割的历史情况进行了实证研究。“大”模式显示,.目前全省的风险基金提取过多,基金累计结余过大。在补偿时应提高村级门诊、乡级门诊、县级住院和县外住院的补偿比例,维持乡级住院比例,降低县级和县外级的门诊补偿比例。“中”模式显示,在基金使用上,基本呈现收入越低,基金使用率也越低的情况。在统筹基金的支出上,明显呈现低收入县<中收入县<高收入县的情形,说明高收入县的参合农民对基金使用的比例更大。低收入县提取了最多的风险基金,偏向保守。低收入县在乡级门诊、县外门诊和县外住院分割基金高于其他县,中收入县在村级门诊、县级门诊分割基金最多,高收入县在乡级住院和县级住院中分割基金最多。三个县都以县级住院分割基金最多,全超过了30%。高收入县侧重住院补偿,中低收入县门诊利用多,但因为住院治疗能力差,选择到外地的比例较高。低中高各县的门诊总体使用基本呈下降趋势,住院利用呈明显上升趋势,但速度过快引发透支。低收入县在村级门诊、县级住院上的补偿较接近专家标准,中收入县在县外门诊与住院上的补偿较接近专家标准,高收入县在乡级门诊、乡级住院和县级门诊上的补偿更符合专家标准。三个县的门诊统筹比较符合标准,家庭账户逐渐进入消亡阶段,体检基金得到了有效控制,特殊病种补偿有所提高。不足之处主要是透支严重,住院统筹使用过度,高收入县还有大量的二次补偿。虚拟县绝大多数数据与全省数据特点的契合说明虚拟县可以作为全省的大样本来研究。“小”模式显示,2003-2004年期间,因为初次试点,基金分割基本没有,只有门诊基金与住院基金的混合支出。2005-2006年期间基金使用变动剧烈,受益率低。三个样本县住院补偿的情况总体要好于门诊补偿,但结余过多和透支也经常同时存在。各种基金中风险基金的分割较好,体检和二次补偿比较乱,家庭账户更是造成门诊补偿的严重被动,不改革已经不行。政策建议1、提高对新农合基金分割重要性的认识。做好新农合的基金分割,就是扼住了新农合筹资、分配、补偿和监管四阶段中的咽喉,对防止基金过大结余和过度透支具有非常重要的作用。2、调整新农合基金分割中的不良做法。原来基金分割中的体检基金和住院分娩基金,应该统一由公共卫生基金来承担,去掉二次补偿基金项。降低当年结余基金的比例,在可控范围内加大对累计结余基金的利用。3、提高统筹层次和筹资水平,提高可分割基金的总量。要加大中央和省级财政对地方的支持力度,切实增加农民的人均收入以尽快提高总体筹资水平。在试点市级统筹的基础上,逐渐向省级统筹过渡。4、配合医改做好费用控制工作,减少基金分割后的浪费。由财政加大对公立医疗机构的补偿力度来降低他们以药养医的冲动,推行基本药物制度,加快预付制、单病种限价等支付制度改革,推行临床路径、分级医疗等有效控制医药费用的配套改革。5、理顺医疗机构的体制,减少基金分割带来的利益冲突。加快理顺体制,乡镇医院实现上划县级管理,村级定点医疗机构实行彻底的一体化,同时加强省、市级大型医疗机构对基层的“强基”工作。6、加强基金监管等配套工作,充分发挥基金分割的优势。加强对基金的审核监管,做到专款专用,透明花费。此外,还要做好基层新农合基金管理人才的培养工作、农民的健康教育工作、健全公共卫生体系工作、加强基层医疗卫生服务体系建设工作等基础性配套项目。主要创新首次探求了新农合基金分割理论,系统阐述了其思想依据、遵循原则、内涵、外延等。首次建立了山东省新农合基金分割模型,并结合医改政策和现实经验提出了基金分割的理想化模型。实证研究中首次创立了“虚拟县”的概念。更多还原

【Abstract】 BackgroundLacks the medical marketability reform which controls to create the medical expense excessively quickly rise, for did not have the basic safeguard farmer to create the pressure which generally was unable to withstand the load. In 2003 our country reconstructed the New Rural Cooperative Medical System (hereafter refers to as NCMS) , proposed to the fund division by the big sickness overall plan goal primarily, received decides, the balanced revenues and expenditures essential requirements, public, fair, fair assignment principle, as well as division scope and so on proper attention to both physical examination limits. The NCMS gathers the fund the movement process to divide into the fund raising, the division, to compensate and to supervise four stages. The fund division is approximately this system from the fund raising the middle link which can move smoothly to the compensation. At the same time, because the fund total amount which collects is getting bigger and bigger, the cake did Has been big, but the fair division cake’s mechanism and the rule have not established. After causing old was unfair breaks, to appear newly is unfair, causes the minority groups to hasten the attenuation.In Shandong Province’s practical work, the most various counties every year must according to the fund raising, ’the compensation and the surplus situation analyzes the reckoning same year’ s fund to divide whether reasonably, how to make the adjustment and the improvement next year, but because some county’ s administrative peoples changed frequently, sometimes will present some not to have the NCMS to gather experience’ s leadership to be responsible for the decision-making, or original administrative peoples to new policy and new situation negligence, also will create some fund division and the use aspect question unavoidably.Once the movement plan after the examination public announcement,within one year could not make the big revision in principle, then easy to cause the question the further accumulation aggravation.Therefore, establishes the science, reasonable, to adapt the Shandong Province actual fund division and the use mechanism, regarding promotes the entire province regional NCMS to gather system’s unceasing consummation, the enhancement management quality and the effectiveness, has the great importance the theory significance and the practical significance.But after retrieval literature, I discovered that domestic does not have the system to study the NCMS to gather the fund division theory and the model report, is the minority empirical study mainly about the compensation pattern classification, how the influencing factor and big sickness slight illness limits and so on question limited research, theoretically has the classified confusion and many flaws. Therefore needs to gather according to the NCMS the experiment site, the advancement and the popularization law of development, carries on a time thorough system’ s NCMS to gather the fund division theory the research, arranges by the time blurs the place, to raise the senior staff to gather the farmer well to profit the level to serve.GoalsThe general goals are gather the fund division from the theory and the real diagnosis aspect to Shandong Province’ s NCMS to carry on the: scientific approach, and carries on the real diagnosis using the design model, found the science in order to the division method, will consummate the NCMS for the present to gather the system to provide profits from and refers to.Theoretical side: take the welfare economics theory, the social security theory, most superior economics and the sociological aspect’ s and so on resources deployment theory, decision theory as a foundation, unifies our country and Shandong Province’ s NCMS gathers the formulation the general and specific policies, to discuss to establish the NCMS to gather the fund division the theory, and is clear about its connotation, extension, the establishment principle and so on.Real diagnosis aspect: taking a Shandong Province 2003-2009 year data as the standard, separately to all levels of aspects and so on outpatient service and in hospital disbursement, physical examination, in hospital childbirth, big sickness overall plan, two compensations, venture capital and fund surplus makes the analysis proof, auxiliary and attains the data by thorough investigation’s experience, through vertically and horizontally compares, reveals present Shandong Province NCMS gathers the question which, the origin the fund division aspect exists and so on.Model aspect: Using the Delphi method primarily, gathers the technical guidance expert storehouse take the Shar dong Province NCMS the expert advice as the datum, establishes one to have the serviceability and the feasibility Shandong Province NCMS gathers the fund division standard, so that each overall plan unit may quite be according to the above convenient adjusts every year’s fund allocation quickly, the solution blind decision-making brings the excessive surplus with exceeds expenditures excessively influence fund use efficiency questions. And may use this model, to confirm passing each overall plan unit fund division efficiency.Finally, propose the policy suggestion that completes the fund division.Data and techniqueThe material mainly comes from three aspects: first, reference; second, scene investigation and study material; third, the material of the expert consulted.According to the different research goal, has adopted the different research technique. Gathered the fund division fundamental research to the NCMS to use the literature review law, deductive line or method of reasoning and so on. Gathered the fund division model study to the NCMS, has used the improvement Delphi law. Gathered the fund division empirical study to the NCMS, used has determined the nature of with the quota unifies the method which, the spot investigation and the literature material unified. Regarding the numerical variable material, use the standard deviation of mean value, missed, targets extremely and coefficient of variation. Regarding the classified variable, with rate, the constitution compared, targets and so on. In addition, also has utilized methods such as comparison analytic method, lamination sampling method, statistical modeling.FindingsIn the fundamental research aspect, through and has profited from the domestic and foreign partial economics, the sociological theories to formerly the policy research, in domestic proposed for the first time the NCMS gathers the fund division the theory, the connotation and the extension and so on, and had determined guarantees the basic principle, the availability and the time-limited principle, the balanced principle, fairness principle, the efficient principle, has unified planning the principle basic principle. Proposed to rejects the physical examination fund, in hospital childbirth fund establishment in the existing fund division, transfers undertakes by the public health special fund. Proposed the method, removed two compensation funds into the disposable adjustment compensation .In the model study aspect, has established expert’ s fund division"the golden standard" , inferred the digitized NCMS to gather the funddivision model. We may see through the model, the year fund raising andthe graduation medical establishment’s compensation compared to having the related relations, in the partial values may estimate or under the fait accomplice premise, can carry on the calculation to other values, or carries on the trimming through the adjustment proportion or the amount, thus enables the policy maker to be possible to act according to the localactual situation to decide how to design the overall concept. This model, may prevent to pat the head decision-making effectively the malpractice. In the compensation compares the hypothesis under the premise, may also calculate approximately in the future needs to finance the total, will serve for the future fund collecting. May also compile the expert the opinion the proportion value direct substitution model, adjusts some item of expense the fund disbursement. At the same time, for model feasibility, also inferred the model five limiting condition according to the policy.In the empirical study aspect, had devised "Big" , "Middle" , "Small" three patterns, from the angle of entire province, the angle of different income type county and the angle of small sample county gathered 2003-2009 year fund division to the Shandong Province NCMS the historical situation to conduct the empirical study. "Big" the pattern demonstrated that at present the entire province venture capital withdraws excessively much, the fund accumulation surplus is oversized. When compensation should raise the compensation proportion which the village-level outpatient service, outside the township level outpatient service, the county level in hospital and the county are hospitalized, the maintenance township level in hospital proportion, reduces county level and outside the county the level outpatient service compensation proportion. "Middle" the pattern demonstrated that in the fund using, presents the income to be lower basically, fund utilization ratio also lower situation. In the overall plan fund’ s disbursement, presents the low income county < income county < high income county obviously the situation, explained that the high income county the senate gathers the farmer to be bigger to the fund use proportion. The low income county withdrew most venture capitals, the deviation which has been conservative. The low income county outside the township level outpatient service, the county outside the outpatient service and the county is hospitalized the division fund to be higher than other counties, the income county in the village-level outpatient service, the county level outpatient service division fund are most, the high income county divides the fund in the township level in hospital and the county level in hospital to be most. Three counties are most by the county level in hospital division fund, all has surpassed 30%. The high income county stress in hospital compensation, the mid and low earning county outpatient service uses much, but because hospital treatment ability is bad, chooses the outside areas the proportion to be high. Their outpatient service overall use assumes the declining trend basically, in hospital use assumes the obvious trend of escalation, but the speed excessively quickly initiation overdraws. The low income county in the village-level outpatient service, the county level in hospital’ s compensation close expert standard, the income county outside the county in the outpatient service and in hospital compensation close expert standard, the high income county in the township level outpatient service, in the township level in hospital and the county leveloutpatient service’ s compensation conforms to the expert standard. Three county’ s outpatient service overall plan comparison meet standards, the family account entered the withering away stage gradually, the physical examination fund was under the active control, and the special sickness planted the compensation to improve. The deficiency is mainly overdraws seriously, in hospital overall plan overuse. The high income county also has the massive two compensations. The hypothesized county overwhelming majority data and entire province data characteristic’ s conjunction explanation hypothesized county may study originally as the entire province detail drawing. "Small" pattern to demonstrate, during 2003-2004 year period, because the primary experiment site, the fund division does not have basically, only then outpatient service fund and in hospital fund mix disbursement. 2005-0006 period fund use change is fierce, the benefit factor is low. Three sample county in hospital compensation’s situation overall is friends with in the outpatient service compensation, but creates surplus are excessively many and overdraws also frequently also exists. In each kind of fund venture capital’s division is good, the physical examination and two compensations are quite chaotic. The family account creates the outpatient service compensation seriously passive, did must be reformed already.Suggestions1st, enhance the understanding of the fund division important to the NCMS. Completes fund division which the NCMS gathers, blocked the NCMS to gathering the fund raising, the assignment, the compensation and the supervision in four stages the pharynx and larynx, to prevented the fund oversized surplus and overdraws excessively has the very vital role.2nd, adjusts the bad procedure of the NCMS to gather in the fund division. Originally in the fund division’ s physical examination fund and in hospital childbirth’ fund, should unify by the public health fund undertakes, removes two compensation fund item. Reduced creates surplus the fund in the past the proportion, enlarged in the controllable scope to the accumulation surplus fund use.3rd, enhance overall plan level and the fund raising levels, enhance the total quantity of the fund that may divided. Must enlarge the central committee and the provincial level finance to the place support dynamics, increases farmer’ s per capital national income by to raise the overall fund raising level as soon as possible earnestly. In the foundation of experiment site municipal overall plan, gradually transits to provincial level overall plan.4th, coordinate medicine redoes the expense control work, after reducing the fund division waste. Enlarges reforms by the finance to the public Medical establishment’ s compensation dynamics reduces them, to raise medical by the medicine the impulsion, carries out basic drug system, speeds up the prepay system, limit the price and so on . Carries out clinical way, the graduation medical service and active control medicine expense coordinated reforms.5th, straighten out Medical establishment’ s system to reduces the conflicts of interest which the fund division brings. Speeds up the straightening out system, the villages and towns hospital realizes delimits the county level management, the village-level fixed point Medical establishment implements the thorough integration, simultaneously strengthens the province, the municipal large-scale Medical establishment to the work of "Strong Base" .6th, strengthens the fund supervision necessary work and displays the fund division fully the superiority. Strengthens to the fund verification supervision, achieves earmarks a fund for a specific purpose, transparent expenditure. In addition, must complete the foundational necessary project of basic unit NCMS to gather the fund management talented person’ s raise work, farmer’s health education work, the perfect public health system work, to strengthen the basic unit health services structure construction work and so on.InnovationSought the NCMS to gather the fund division theory for the first time, elaborates its thought rested on, the principle, the connotation, the extension and so on sisterly. Established the Shandong Province NCMS to gather the fund division model for the first time, and unified the policy of medicine reform and the reality experience proposed the idealized model on fund division.. In the empirical study established the concept "hypothesized county" for the first time.更多还原