【作者】 桑新刚；

【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， 2011， 博士

【摘要】 研究背景新型农村合作医疗制度是由政府组织、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。自2003年试点运行以来,制度建设和保障效果不断得到完善与增强。到2009年底,覆盖超过94%的农村人口,累计补偿超过15亿人次,补偿金额超过1200亿元。但是,新农合制度发展的瓶颈也逐渐显现——在覆盖率和资金规模不断提高的背景下,如何不断增强新农合制度的保障能力?日前,我国农村地区慢病流行越来越严重,慢病经济负担越来越沉重,慢病已经成为危害农村居民健康与经济风险的主要来源。慢病是一种可以通过干预实现有效预防、控制的一种疾病。由于慢病具有周期长、逆转性差等特点,要求慢病患者需要长期治疗,门诊费用及购药费用成为慢病患者疾病经济负担的主要来源。慢病的特殊性决定了其保障的特殊性。新农合制度对慢病患者保障不应仅仅是对其进行经济补偿,更重要的是通过医疗保障引导慢病患者合理选择就诊机构,通过医疗保障促进预防、保健等公共卫生服务的开展,实现对慢病患者保障的关口前移,从根本上降低慢病发病率,实现对慢病患者的保障。研究目的本研究的目标是在研究新农合制度保障慢病患者能力内涵与评价体系的基础上,分析新农合制度对慢病患者的保障能力,结合慢病保障的特殊性,提出新农合制度加强对慢病患者保障的措施。具体目标包括：1)研究新农合制度对慢病患者的保障能力的内涵与评价体系；2)分析新农合制度对农村慢病患者的保障能力,明确问题与影响因素；3)提出加强新农合制度对慢病患者保障能力建设的政策建议。资料来源本研究资料主要来源于文献复习和现场调查。文献资料来源于山东大学图书馆,包括电子期刊、杂志以及纸质图书以及国家宏观卫生统计资料、国家卫生服务调查等资料；调查数据来源十卢森堡-WHO-山东《山东省农村卫生人员培训与慢病控制项目》2007年基线调查和2010年终期调查的数据,包括入户调查、机构调查和关键人物访谈等。研究方法本研究在文献综述的基础上,对新农合制度的社会保险属性与新农合制度对参合农民保障的路径进行了分析,研究了新农合制度对慢病患者保障能力的内涵。以保障能力内涵为基础,结合对现有新农合制度保障能力的综述,本研究建立了新农合制度对慢病患者保障能力的评价体系。从广度、深度与高度三个维度构建了新农合制度对慢病患者核心保障能力评价框架与指标体系；从保障健康和规范供需双方行为、促进慢病服务社会化三个纬度构建了新农合制度对慢病患者延伸保障能力的评价框架。研究方法包括系统分析法、文献综述法、专家咨询法等。分析采用EXCELL、SPSS统计软件进行分析。主要结果与发现1新农合制度对慢病患者保障能力的内涵及评价体系新农合制度的性质与功能是决定其保障能力内涵的基础。2003年试点之初,新农合制度被定义为“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。”在此之后有多位研究者认为新农合制度在推广过程中已经逐渐具备了社会医疗保险的属性。2010年10月,第十一届全国人民代表大会常务委员会第十七次会议审议通过的《中华人民共和国社会保险法》正式将新农合制度纳入到我国社会医疗保险制度范畴内,标志着新农合制度正式成为我国社会医疗保险的组成部分。根据医疗保险与社会医疗保险理论,新农合制度作为我国政府在农村地区建立的一项基本社会医疗保险,应该具备社会福利性、强制性、经济性和公益性,在具备保障参合农民经济风险的核心能力的基础上,还应具备保障慢病患者健康、引导慢病患者合理就医和促进公共卫生服务的能力。理论上,新农合制度主要通过以下几个途径给予慢病患者保障：直接补偿慢病患者在各级卫生机构产生的医疗费用,补偿慢病患者购药产生的费用：引导慢病患者合理选择就诊机构降低医疗费用；促进向慢病患者提供公共卫生服务,包括健康查体、建立健康档案,以降低慢病发病率和控制病情发展。以新农合制度属性和功能为基础,结合新农合制度保障慢病患者的途径,综合慢病保障的特殊性,本研究认为新农合制度对慢病患者的保障能力分为两部分：核心保障能力,即抵抗经济风险的能力和延伸保障能力,即通过促进居民卫生服务可及性以保障居民健康的功能、规范参合居民就医行为的功能和促进健康查体、建立健康档案等慢病卫生服务社会化的功能。2农村慢病流行情况基线调查时,农村地区高血压的患病率为10.50%,男性高于女性,高收入组最高,男性并发症发生率高于女性；糖尿病患病率为1.05%,女性高于男性,高收入组最高；其他慢病的患病率为7.21%,以冠心病、阻塞性肺疾病为主,患病率分别为2.27%和1.38%。终期调查时,高血压和糖尿病患者的患病率分别为17.19%和3.04%。3样本地区新农合制度对慢病的优惠补偿政策基线调查时,莱城区、广饶县、宁阳县和苍山县制定了新农合制度对慢病的优惠补偿政策。终期调查时,8个样本县均制定了新农合制度对慢病优惠补偿政策。门诊补偿：项目县(市、区)新农合制度慢病优惠政策中,一级医疗机构门诊报销比例为30%-60%,以30%-45%之间为主。住院补偿：项目县(市、区)新农合制度慢病优惠政策中,新农合制度对慢病患者乡镇卫生院(一级医院)住院报销比例在40%-70%之间,二级医院住院报销比例15%-70%之间。4新农合制度对慢病患者保障能力分析1)新农合制度对慢病患者的核心保障能力分析。主要包括广度分析、深度分析和高度分析。①广度指标分析发现：基线调查时,新农合制度对慢病患者的覆盖率已经超过了90%。两次调查新农合制度对高血压、糖尿病患者的覆盖率分别为93.61%,92.04%和92.60%和86.52%,对高收入患者的覆盖率高于低收入患者。按照我国民政部门贫困标准,两次调查对高血压和糖尿病患者致贫率降低的幅度分别为1.32%,5.17%和9.12%,4.00%,对高收入患者的影响大于对低收入患者的影响,样本地区之间存在差异。按照世界银行标准,两次调查对高血压和糖尿病患者致贫率降低的幅度分别为1.54%,2.70%和8.71%,3.45%,对高收入患者的影响大于对低收入患者的影响,样本地区之间存在差异。基线调查时慢病患者的受益率为29.84%。两次调查,高血压和糖尿病患者的受益率分别为28.64%,27.84%和45.56%,29.08%,不同收入组之问受益率没有统计学差异,样本地区之间存在差异。②深度指标分析发现：新农合制度对慢病患者的补偿比为4.71%,其中高血压患者一次门诊、住院的补偿比分别为4.65%,11.39%,糖尿病患者的补偿比分别为5.71%,16.91%,其他慢病患者一年费用的补偿比为4.23%；两次调查新农合制度对高血压和糖尿病患者一年的补偿比分别为4.34%,4.95%和26.98%,24.10%,对高收入患者的补偿比略高于低收入患者。新农合制度补偿降低高血压患者一次门诊、住院的灾难性卫生支出平均差距分别为6.54%,13.13%,降低糖尿病患者一次门诊、住院的灾难性卫生支出平均差距分别为2.87%,26.99%,其他慢病患者为8.07%。两次调查显示,新农合制度降低高血压和糖尿病患者一年费用的灾难性卫生支出平均差距分别为11.64%,4.66%和26.69%,48.10%,对高收入患者的影响程度较大,不同样本地区之间存在差异。按照民政部贫困标准,新农合制度补偿降低高血压患者一次门诊、住院贫困缺口率的幅度分别为0.22%,29.17%,糖尿病患者的两项指标分别为2.02%,7.69%,其他慢病患者的指标为10.33%；两次调查,新农合制度降低高血压和糖尿病患者贫困缺口率的幅度分别为2.08%,20.34%和15.98%,13.13%,对不同收入高血压患者影响没有统计学差异,对高收入糖尿病患者影响程度较大。按照世界银行的标准,新农合制度降低高血压患者的一次门诊和住院贫困缺口率的幅度分别为0,22.54%,糖尿病患者分别为0.91%,6.42%,其他慢病一年指标为14.29%。两次调查显示,新农合制度降低高血压患者和糖尿病患者贫困缺口率分别为1.93%,9.09%和11.76%,8.33%,对不同收入高血压患者的影响没有统计学差异,对高收入糖尿病患者的影响大于低收入患者。③高度指标分析,即公平性指标分析。筹资公平性：高血压、糖尿病和其他慢病患者的筹资公平性指数分别为0.9831,0.9968和0.9954,终期调查时,高血压和糖尿病患者的筹资公平性指数分别为0.8162和0.8123,较基线调查时有所降低。补偿公平性：按照收入由低到高,不同收入组患者年自付医疗费用占个人可支配收入的比例分别为262.00%,138.15%,71.23%,47.65%和29.12%。两次调查时,慢病患者补偿Lorenz曲线均位于绝对公平线下方,高收入组患者获得的新农合制度补偿高于低收入组患者。2)不同补偿比时新农合制度对慢病患者的保障能力测算。分别以门诊补偿比例为20%,30%,40%和50%时,住院补偿比例为40%,50%,60%,70%时,对新农合保障慢病患者的能力进行了测算。门诊补偿比例由20%增加到50%,新农合补偿降低高血压患者致贫率的幅度由7.32%上升到28.21%,降低灾难性卫生支出平均差距的幅度由15.73%增加到41.91%,降低贫困缺口率的幅度由8.41%增加到35.01%。门诊补偿比例由20%提高到50%,糖尿病患者人均获得新农合门诊补偿的金额从211.31元增加到762.62元,降低贫困率的幅度由16.54%增加到31.13%,降低灾难性卫生支出平均差距的幅度从10.01%升高到30.23%,降低贫困缺口率的幅度由9.89%增加到30.43%。住院补偿比例有40%增加到70%,新农合制度降低高血压患者贫困率的幅度由21.57%增加到35.21%,降低灾难性卫生支出平均差距由16.32%增加到30.61%,降低贫困缺口率由40.64%增加到56.72%。对糖尿病患者住致贫率降低幅度由6.78%增加到26.01%,降低灾难性卫生支出平均差距由37.61%和53.24%,降低贫困缺口率由16.35%升高到32.42%。3)新农合制度对慢病患者延伸保障能力分析。①两次调查显示,高血压患者和糖尿病患者的四周就诊率分别提高了8.63%和7.63%,住院率分别提高了54.07%和2.01%。②高血压患者和糖尿病患者最近一次门诊选择村卫生室的比例分别提高了11.74%和317.04%,低收入患者提高的幅度大于高收入患者；高血压患者选择乡镇卫生院住院的比例分别提高了108.16%。③高血压患者和糖尿病患者从村卫生室购买药物的比例分别提高了15.46%和79.44%,低收入患者选择村卫生室购药的比例升高,而高收入患者选择村卫生室购药的比例下降。④样本地区制定了规范定点医疗机构服务行为的措施,包括明确机构责任、医生处方行为等。其中,寿光市新农合制度管理办公室专门制定了《寿光市新型农村合作医疗特殊慢性病门诊统筹》,对慢性病定点医疗机构的职责做出了明确规定。⑤样本地区多开展了新农合制度健康查体措施,并结合健康查体为农民建立了健康档案。不仅提高了农民参合的积极性,更有效的实现了对慢病高危人群的早发现、早干预,以及对慢病患者的疾病管理,控制了病情的发展。结论及政策建议本研究认为新农合制度对慢病患者的核心保障能力与全人群水平还有一定差距；新农合制度对慢病患者的延伸保障能力还存在较大潜力,需要进一步挖掘,以提高新农合制度保障能力。新农合实行慢病优惠补偿政策以及其他相关措施以后,新农合制度对慢病患者的保障能力有明显提高。为进一步提高新农合制度对慢病患者的保障能力,结合慢病保证的特殊性与分析结果,本研究提出以下建议：提高基层卫生机构新农合制度报销比例,增强新农合制度保障慢病患者的效率；提高新农合制度补偿比例,增强新农合制度降低慢病患者“因病致贫”能力：实行慢病患者与非慢病患者差别管理,增强新农合制度保障慢病患者的能力；提高慢病患者门诊补偿标准,增强新农合制度保障慢病患者的针对性；将慢病逐步纳入大病统筹,增强新农合制度对特殊人群的保障能力；关注慢病患者药店购药行为,引导慢病患者合理选择购药机构；资金使用向贫困人口倾斜,提高新农合制度补偿公平性；将新农合制度与农村基本公共卫生服务工作有机结合,促进慢病预防控制工作更多还原

【Abstract】 BackgroundNew rural cooperative medical scheme (NCMS) is a form of social health insurance scheme, which, since its inception in 2003, is subsidized voluntary health insurance program. The scheme’s focuses on the "inpatient-fee pool", and also pay attention to the outpatient expenditure. Since the pilot in 2003, the scheme has been developed rapidly while the coverage and the fund have both got new high level. At the end of 2009, the scheme has covered more than 94%of rural residents, and more than 1.5 billion person times got reimbursements from scheme, and the total reimbursement was more than 120 billion RMB yuan. However, the barrier of NCMS’long-term development is becoming clearer:with the rapid development of coverage and fund, how to improve the NCMS’capacity of protecting?At present, the prevalence of non-communicable diseases (NCDs) in rural China is becoming serious, while the disease economic burden becoming heavier and heavier. The NCDs have become the major cause of rural residents’ health and economic risk. In accordance with the NCDs prevention theory, the NCDs’ prevention should follow the "three early" principle, which is early find, early diagnose and early treat. The "three early" principle helps to reduce the incidence of NCDs and finally reduce the economic risk of rural residents with NCDs. However, because we did not recognized the importance of NCDs control during the social-economic change, the incidence of NCDs is getting higher rapidly while the economic burden is getting heavier. Under the circumstance, the first job is to establish the health insurance in order to reimburse the rural residents with NCDs. So that their health care availability will be improved and they will get their health insured.Now, the NCMS the only health insurance which aims to cover all the rural residents protects rural residents. Only to clear the denotation of NCMS’capacity of protection and the current situation of NCMS protecting rural residents with NCDs, can we improve the NCMS in order to strengthen its protection capacity.ObjectivesThe objective of the study is to analyze the NCMS’s capacity of protecting rural residents with NCDs. and to suggest the recommendations for improving the NCMS in the future on the basis of studying the denotation of NCMS’protecting capacity and the evaluation. The following special objectives are included:studying the denotation and the evaluation system of NCMS" capacity of protecting rural residents with NCDs, analysis of the current situation of NCMS’ ability in protecting rural residents with NCDs and making the shortcomings and the advantages clear, supposing recommendations to improve the NCMS’capacity of protecting rural residents with NCDs.ResourcesThe resources of the study include the literatures and investigation. The literatures come from the library of Shandong University, including e-books, e-magazines, books and macroscopically health statistics data basis. The investigation datum roots in baseline investigation and final investigation of Luxemburg-WHO-Shandong rural health workers training and chronic non-communicable diseases control program, including household investigation, institution investigation and informational interview.MethodologyThe study analyzes the pathway of NCMS protecting rural residents with NCDs based on the literature review, then studies the denotation of NCMS’ capacity of protecting rural residents with NCDs.Taking denotation of NCMS’protect ability as the basis, the study constructs the system for evaluating NCMS’ protect ability for rural residents with NCDs combining literature review on NCMS protect ability. The evaluation system for NCMS’ core protect ability includes breadth, depth and height; the connotative protect ability includes guarantee health of rural residents with NCDs, regulating the health providers’and demanders’behavior, promoting the health care for NCDs to be socialized.The study methods include systematic analysis, literature review, expert consultation and so on. Univariate analysis and description analysis with SPSS software are used to address the data.Results and findingsI The denotation and evaluation system of NCMS’s ability to protect rural residents with NCDsThe nature and functions determine the denotation of NCMS’s ability of protecting rural residents with NCDs. At the beginning of pilot, the NCMS was defined as a commune to help system between rural residents. After that, lots of researchers argued that the NCMS has got the nature of health insurance. In October,2010, the Insurance Law of Peoples Republic of China take NCMS as an health insurance, which meaned that NCMS have become part of health insurance system and got the nature of health insurance. In accordance with the theory of health insurance and social health insurance, NCMS should perform social welfare, mandatory, economy and public welfare as one of social health insurance of our country. Besides the core ability, reducing economic risk of rural residents with NCDs, NCMS should also have the function of guaranteeing the health of rural residents with NCDs, regulating health providers’and demanders" behavior, and making health care for controlling NCDs be socialized, which includes health examination and establishment of health files.Theoretically, NCMS protects rural residents with NCDs by three pathways:directly reimburse health expenditures occurring in health organizations and drug stores, guide the rural residents with NCDs reasonably chose health organizations, provide public health care, including health examination and establishing health files, to rural residents with NCDs.On basis of nature and functions of NCMS, the paper argues that NCMS’ability of protecting rural residents includes two parts:core ability, which means reducing economic risk, and connotative ability, which means guaranteeing health, guiding health behavior and public health care.2 Prevalence of NCDs in rural areasThe prevalence of hypertension and diabetes in rural areas was 10.50%and 1.05%, prevalence of female is higher than male, high incomes higher than low incomes when baseline investigation. The other NCDs includes cardiovascular and COPD and so on. The final investigation shows that the prevalence of hypertension and diabetes is 17.19%and 3.04%, which is relatively lower than that of baseline.3 The NCMS policy on reimbursement to rural residents with NCDsIn 2007, there were four counties, Laicheng, Guangrao, Ningyang and Cangshan, which made NCMS policies on reimbursement to rural residents with NCDs, while the number become eight in 2010. In accordance with the policies, the reimbursement ratio of outpatient in township health center is between 30%and 60%, which is between 30%and 50%in county hospitals. The reimbursement ratio of inpatient is between 40%and 70%in township health centers, which is between 15%and 70%in county hospitals.4 Analysis of NCMS ability of protecting rural residents with NCDs1) Analysis of NCMS’core ability of protecting rural residents with NCDs. NCMS has covered more than 90%of the rural residents with NCDs in 2007. And the coverage of hypertension and diabetes is 93.61%,92.04%and 92.71%,86.52%respectively in 2007 and 2010. NCMS covers more high income rural residents with NCDs. On basis of China poverty line, NCMS reduce poverty rates of hypertension and diabetes by 1.32%,5.17% and 9.12%,4.00%respectively in 2007 and 2010, which is higher in high income patients, so is between sample counties. In accordance with World Bank poverty line, NCMS reduce poverty rates of hypertension and diabetes by 1.54%,2.70%and 8.71%,3.45%in 2007 and 2010 respectively, which is higher in high income patients, so is between counties. The benefit rate was 29.84%in 2007. which of hypertension and diabetes is 28.64%,27.84%and 45.56%,29.08%in 2007 and 2010 respectively, which is different between counties.The ratio of reimbursement for rural residents with NCDs was 4.71%, while the ratio of reimbursement for one outpatient and inpatient was 4.65%and 8.39%respectively in 2007. The ratio of reimbursement for diabetes’ outpatient and inpatient was 5.71%and 7.91% respectively, while the other NCDs was 4.23%in 2007. The reimbursement ratio for hypertension and diabetes annual health expenditure is 4.34%,4.95%and 26.98%,24.10% respectively in 2007 and 2010, which is a little higher in high income patients. NCMS reduces the catastrophic health expenditure gap of hypertension outpatient and inpatient was 6.54%and 13.13%respectively in 2007, which of diabetes was 2.87%and 26.99% respectively. The catastrophic health expenditure gap of hypertension and diabetes reduced 11.64%,4.66%and 26.69%,48.10%respectively by NCMS in 2007 and 2010. In accordance with China poverty line, NCMS reduce positive poverty gap of hypertension outpatient expenditure and inpatient expenditure was 31.35%and 1.57%respectively in 2007, which of diabetes was 8.04%and 6.16%respectively. NCMS reduces the positive poverty gap of hypertension and diabetes by 26.28%,15.98%and 20.34%,13.13%respectively in 2007 and 2010, which is higher in high income rural residents with diabetes. On basis of World Bank poverty line, the positive poverty gap of hypertension outpatient and inpatient expenditure was reduced by 0 and 22.54%respectively in 2007, which was 2.28%and 6.42%respectively. NCMS reduces the positive poverty gap of hypertension and diabetes annual health expenditure by 1.93%,21.57%and 9.09%,58.33%respectively in 2007 and 2010. The equity of protect ability shows that the index of financing equity for hypertension patients, diabetes patients and other NCDs patients was 0.9831,0.9968 and 0.9954 respectively in 2007, which of hypertension and diabetes is 0.8162 and 0.8123 respectively in 2010. The Lorenz curve is below the absolute equity curve, which means that the reimbursement of NCMS concentrates in high income crowd.2) Analysis of the NCMS’s capacity of protecting rural residents with NCDs under different reimbursement ratio. The paper analyses the NCMS’s capacity of protecting rural residents with NCDs with the outpatient reimbursement ratio is 20%,30%,40%and 50%respectively, and the inpatient reimbursement ratio is 40%,50%,60%and 70%. When the ourpatient reimbursement rarion increased to 50%from 20%, the percentage change of poverty ratio increased to 28.21%from 7.32%, which of catastrophic health expenditure poverty increases to 41.91%from 15.73%, and that of positive poverty gap increases to 35.01%from 8.41%.3) Analysis of NCMS’connotative capacity of protecting rural residents with NCDs Percentage of hypertension patients and diabetes patients visit doctor in four weeks prior the investigation increases by 8.63%and 7.63%respectively, while the percentage of inpatient attendance increase by 54.07%and 2.01%respectively. Percentage of rural residents with hypertension and those with diabetes chose village clinic center increase by 11.74%and 317.04%respectively. And the difference is significant among income group. The low income patients are affected more by the policy change. And the percentage of hypertension patients who have inpatient services in township health center increase by 108.16% significantly. The percentage of rural residents with hypertension and those with diabetes who buy medicine from village clinic center increase by 15.46%and 79.44%respectively, while low income patients prefer village clinic center better than the high income patients. To regulate health providers" behavior, the management office of sample counties all made measurements, such as clearing the responsibility of health organization, prescription of doctor and so on, in order to control the health expenditure. Especially, the management office of NCMS in Shouguang constructs regulations on chronic outpatients funds pool of new rural cooperative medical scheme>, which make the special responsibility of health provider clear. At the same time, NCMS in sample counties also provide health examination to rural residents who participate into NCMS, and establish health files for them. These measurements not only let more rural residents like to participate in NCMS, but also make the "early find" and "early intervention" to NCDs come true on basis of NCDs patient management. Finally, these measurements which will help strengthen NCMS’s ability to protect rural residents with NCDs will help control the disease development and reduce the economic risk.Conclusions and recommendationsThe study argues that the breadth index of NCMS protect rural residents with NCDs is higher than average of total group, however the depth index is far below the average of total group of NCMS while the height index is similar. Therefore, the big potential protect ability need to be developed. Overall, NCMS’s ability to protect rural residents with NCDs is weak.In order to improve NCMS’s ability to protect rural residents with NCDs. following recommendations are provided:increasing reimbursement rate in root health care services in order to improve the efficient of protecting rural residents with NCDs, giving rural residents with NCDs more reimbursement in order to help them against "poverty because of diseases" making special reimbursement policy for rural residents with NCDs, increasing reimbursement rate of outpatient, putting NCDs into heavy disease burden pool, giving reimbursement to medicine fee in drug stores, changing equity of reimbursement, combining NCMS with public health works to help improve NCDs prevention.更多还原