【作者】 刘利；

【导师】 王钊；

【作者基本信息】 西南大学 ， 农业经济管理， 2011， 博士

【摘要】 重庆市新型农村合作医疗制度于2003年开始试点,2007年全面推进,并在全国率先开展城乡居民医疗保障一体化探索,于2009年实现了所有区县所有人群医疗保障制度的全覆盖,合作医疗工作成绩显著。伴随制度的不断推进以及各级政府支持力度的加大,重庆农村居民受益范围、受益程度均有所改善,基层医疗机构服务能力得到提升,医疗可及性与可得性得以增强。然而,由于制度设计固有的缺陷以及配套性制度的缺失,供方诱致性需求、过度医疗服务、医患合谋等道德风险和不端行为不断升级,医疗费用连续攀升,新型农村合作医疗制度的受益主体发生偏移,参合农民的利益受到侵蚀,农村居民参合积极性以及制度的可持续性受到影响。因此,系统研究新型农村合作医疗制度运行效果、存在问题、产生问题的制度内外因素以及作用机制,为制度提出路径改进方向及具体政策建议,既是重庆新型农村合作医疗制度发展的需要,也关系到中国城乡居民医疗制度一体化建设的走向。1、研究问题和研究思路本文紧紧围绕影响重庆新型农村合作医疗制度的因素及作用机制这个问题,应用流行病学方法,通过分层随机抽样确定样本人群,深入农村进行了家庭入户调查研究。对收集的数据综合运用定量研究、定性研究、比较研究等方法,对重庆市新型农村合作医疗制度效果、存在问题进行全面分析和评价,从制度框架、医疗供给以及农户3个维度研究分析得出影响新型农村合作医疗制度运行效果的因素及其影响程度和作用机制。最后探讨改进我市新型农村合作医疗制度绩效的路径,提出有针对性的对策和建议。2、研究的主要内容围绕研究问题,主要从以下5个方面展开：(1)国内外医疗保障制度研究。本文通过对国外经典的5种模式以及国内政府主导型4种医疗保障制度进行比较研究,指出各种模式的优势及不足,为农村合作医疗制度的优化提供借鉴和参考。(2)中国农村合作医疗制度的变迁分析。通过对我国农村合作医疗制度的历史变迁研究,进一步明确制度的走向与制度设计和制度环境的密切关系,提出制度选择遵循制度环境和历史规律的必要性。同时还对新型农村合作医疗制度与传统农村合作医疗制度以及其他形式的医疗保险进行了比较,进一步明确新型农村合作医疗制度的本质特点以及与其他形式医疗保障之间的关联,对重庆新型农村合作医疗制度特点进行介绍,以便为后续的制度效果及存在问题及改进路径作铺垫,(3)新型农村合作医疗制度运行现状及存在的主要问题。主要通过大量实地调研,从合作医疗制度的三方利益主体-农民、医疗机构及医生、合作医疗管理监管部门等角度,了解新型农村合作医疗制度的运行情况,为客观分析新型农村合作医疗制度运行效果、实施效率、存在问题提供依据。(4)分析影响新型农村合作医疗制度运行的因素、影响程度及作用机制。这是本研究的核心内容,既是重点,也是难点。主要从制度框架、医疗供给和参合农民3个维度展开。通过分析调研数据,利用相关理论对调研结果进行分析,找出数据背后的逻辑关系和规律,进而得出相关因素的影响程度,发现作用机制。(5)新型农村合作医疗制度优化方向及路径。这是本研究的根本目标,研究的目的,就是在中国特定的政治经济文化等背景下,建立起与具体国情与重庆市情相结合的新型农村合作医疗制度。3、研究的主要结论(1)本文认为,国外典型的5种模式都是在特定的政治经济文化背景产生的医疗保障制度,因此,我国的农村医疗保障制度也必须立足本国实际,在借鉴各种医疗保障制度先进理念与做法基础之上,建立符合国情具有特色的医疗保障制度。具体操作中,要明确政府在医疗保障作用中主体责任,保障制度有效实施；必须建立有效的医疗费用控制机制,防止医疗费用恶性膨胀以及受益主体的偏移；构建医疗保险法律体系,调整规范各主体行为；加强制度配套改革,为合作医疗制度的实施创造良好的外部环境。(2)在有效控制过度服务的情况下,重庆2009年住院医疗费用可以降低到实际费用的54%,门诊费用可以降低到实际费用的75%。根据当年发生的住院与门诊费用情况,测算出实际医疗费用可以整体下降42.1%,农户合作医疗整体报销比例可以提高36%。在此基础之上,本章提出了几种供方控费措施。首先,引入竞争机制,建立以公益医院为主体、公益与赢利医院并存的多层次农村医疗供给体系,满足不同人群、不同层次的卫生服务需要。其次,引入农村居民参与监督与管理,以规避现行管理体制中“花别人的钱办别人的事,既不讲成本也不讲效果”的弗里德曼经典模式之弊端。第三,根据公共产品理论以及医疗产品的层次属性,提出加大政府对基本医疗卫生服务的责任与义务。(3)与现有许多文献研究认为医疗保障中穷人补贴富人的观点有所不同的是,本研究发现,贫困人群2周发病率和住院率均显著性高于平均水平,尽管也存在未就诊率和未住院率高于平均水平的情况,但贫困人群的人均医疗费用、中位数、补偿额度均在其他组人群之上,故逆向补贴现象在本调研中不成立。(4)、由于穷人整个收入以及消费性支出均低,卫生支出比例显著性高于其他组人群,医疗负担明显重于其他人群。在对农村合作医疗制度预期较高的情况下,贫困人群对制度的评价显著性低于整体水平。因此,农村居民对制度的评价与卫生支出占家庭消费性支出的比例相关性更强,而非报销绝对数量。这提示我们在制度设计中加大对贫困地区和贫困人群的转移支付力度的必要性。通过对不同年龄组农村居民的对比研究,发现青年组健康水平高,但该组的参合率,以及在制度更合理的假设条件下愿意提高现有参合费用比例高于老年组和中年组,说明居民逆向选择在制度合理情况下并不明显,进而提出制度优化远比一味强调参合费用低廉更重要的建议。4、政策建议本文认为应该着力从以下方面建立健全医疗保障制度体系：(1)建立多层次医疗保障体系,满足农村居民不同层次的医疗保障需求。以农村合作医疗制度为主体制度,以商业保险为辅助制度,医疗救助或社会捐助为兜底制度。主流制度应采取强制性参加,满足普通居民的基本医疗卫生服务需要；商业保险采取自愿原则,主要是为居民提供大额医疗补偿；医疗救助或社会捐助则主要针对社会贫困人群进行医疗扶助。三个层次的医疗保障制度覆盖不同人群不同层次医疗卫生需要,实行功能互补衔接,纵向积累与横向互济结合,有效解决农村居民医疗卫生的后顾之忧。(2)基金筹集方面,设立家庭健康储蓄账户,鼓励居民为自己的将来、特别是老龄化的到来储蓄准备。通过建立基金纵向积累机制,以达到减轻老龄化社会沉重的医疗负担、扩大新农合基金规模、提高基金保障能力、增强居民医疗费用意识、减少卫生资源浪费、加强民主参与进而控制供方费用增长的目的。(3)补偿设计方面,建立分层、分级、累进医疗补偿机制。由于住院与门诊仅仅是疾病治疗的方式,与大病、小病没有必然联系,根据表象或形式来确定是否补偿以及补偿的比例显然有失科学性与合理性。因此,打破现有的住院与门诊基金分割的模式,以疾病治疗产生的费用(基本治疗范围内)频段为基准,设立相应报销比例,建立分层、分级、累进医疗补偿机制,有利于提高资源利用效率。(4)作好制度设计的配套与衔接。建立参合家庭健康档案,对那些长期未使用医疗卫生资源或利用很少的群体,应适当提高他们患病后的报销比例。建立菜单式的补偿包,为参合居民提供更人性化的选择,满足不同人群的医疗保障需要。5、研究的创新之处本文以相关理论为指导,运用综合研究方法对重庆市新型农村合作医疗制度取得的实效、存在问题、影响因素及影响程度等展开较全面的深入分析,并提出了新型农村合作医疗制度优化的方向和途径,以及促进制度优化的系统政策建议,在研究方法以及研究结论方面具有一定创新性。(1)在研究方法方面。首先,本文除了一般的文献研究、机构调查、个别访谈等方法外,在田野调查法中还融入流行病学调查方法。在预调查基础之上,确立关键指标,利用流行病学样本测算公式,科学测算样本数量。再通过分层、随机抽样方法,获得样本区县和样本乡镇以及样本人群,使整个样本人群具有较强的代表性。其次,本文根据调研数据,设计数学模型演算了医疗供给(过度服务)对合作医疗制度影响机制以及侵蚀参合居民参合利益的程度,得出相关结论。这种定量分析,目前尚未见到相关文献报道。(2)在研究结论及制度优化建议方面。本文指出既有的合作医疗制度设计的诸多问题大多与制度功能及定位不明晰有关,提出在当前筹资水平情况,新农合制度定位于农村居民的基本医疗保障比较合适,不应赋予新农合制度太多无法承担的责任。在明确定位基础上,本文提出了制度创新建议。医疗保障体系方面,建立以新农合为主体的多层次农村医疗保障体系；基金筹集方面,实行差异化筹集,并建立家庭健康储蓄账户,鼓励家庭为未来健康储蓄；在做好配套改革基础上,采取强制性参合原则；补偿制度方面,打破门诊与住院基金分割,建立统一的以费用为基础的分层、分级、累进补偿机制。这些制度优化建议均具有一定创新性。更多还原

【Abstract】 The new rural co-operative medical system (NCMS) was introduced into Chongqing in 2003 as a sub-type of medical insurance system. There has been a rapid development of NCMS since 2003 and the system has already covered all rural counties of Chongqing by 2007. The city of Chongqing is taking the lead exploring the integration of medical ensuring design between the citizens of city and farmers of countryside and great progress had been made. All farmers of Chongqing became eligible for the coverage of NCMS, effective from 2009.Increased financial support from the government enables more and more farmers enjoy the NCMS in Chongqing. Mean while, various moral and ethical misconducts also come into play, e.g., unnecessary needs or over-service from hospitals, conspiracy between hospitals and patients, which become serious issues affecting the implementation and development of NCMS. It would be impossible to move the NCMS forward if these behaviors are not under control. Therefore, it is urgent for the administrators of NCMS to investigate the effectiveness of operation, existing problems, and functioning mechanisms so that NCMS can be improved systematically.The objective of this dissertation is to study the principle theories of medical insurance, compare the classic models of medical insurance in the world, analyze the historical changes of NCMS in China, investigate the operational effect and existing problems of NCMS in Chongqing, examine the reasons and influence as well as functioning mechanisms of the NCMS and provide suggestions for further improvement of the NCMS. The following eight chapters are presented to address these issues.Chapter 1 includes the objective, significance, main contents, study designs, and general methods of the program.Chapter 2 discusses the rural medical insurance models of foreign countries and a comparative study was designed to analyze the features, pros and cons of five classic international models of health care system including free health care, social medical insurance, medical insurance of business, community health care and medical insurance savings-account.Chapter 3 analyzes the changes of the new rural cooperative medical system in China. Since there are close relationship between system design and system circumstance, it is wise to design NCMS with historical laws.Chapter 4 examines the effects and problems of NCMS in Chongqing via a survey in 1268 rural families. The results show that the progress has been made on alleviating the rural medical burden and improve the accessibility of medical service, while various problems still remain to be resolved.Chapter 5 analyzes the standards, models, methods, principles of raising money and the payment models, and ends with a number of constructive suggests. It is necessary to make different level on fund raising, and make the compensation package with different combination, and adjust the mode of payment.Chapter 6 analyzes the influence and functioning mechanism of medical supply on cooperative medical system. Through agency investigations and data of annals, the author explored the fairness and efficiency of medical supply in Chongqing, examined the reasons of increase in medical cost, and concludes that over-service is the main reason that influences the benefits and willingness of the participants.Chapter 7 analyzes how the family income, gender, and age affect the willingness of the participants, benefit from the NCMS and evaluation on NCMS. It would be better to attract farmers by meeting needs than just low participant fees.Chapter 8 brings forward the optimization method of NCMS in Chongqing.Conclusions:1.To create a unique rural medical insurance system suitable for Chinese, four aspects must be emphasized. First, the government is expected to be responsible for medical insurance of the citizens; second, the mechanisms for the management of medical cost need to be formulated; third, medical ensuring law system needs to be made to regulate the behaviors of benefiters; fourth, the coordinated reforms must be in step.2.The hospitalization costs would decrease 46% and the outpatient costs would decrease 25% if the over-service were controlled effectively. The actual medical cost of Chongqing would decrease 42.1% in general and the reimbursement would increase 36% in 2009.3.The average medical cost and reimbursement of low-income participants are higher than that of the others; therefore, the "converse subsidy" phenomenon does not exist in this research, which is a concern of many researchers in medical insurance.4.The current NCMS can be improved via the following:1) multi-level of medical insurance system must be built to meet different farmers’ different needs.2) Encourage farmers save money for their future medical service.3) Rational and realistic reimbursement mechanism must be made.4) Supporting reforms must be built to improve the NCMS.Directed by pertinent theories, this dissertation gives an in-depth analysis to efficacy, problems, influencing factors and degrees of NCMS in Chongqing by using the multiple research methods, and provides constructive suggests for optimizing the NCMS. There may some innovations on research methods and conclusions:Two unique research methods are used in this study:epidemiological investigation is used to improve the representation of sample, among which stratified random sampling is combined, and mathematical models established by the author is applied to deduce how medical supply affect the NCMS.This study point out that the NCMS should play the role of basic medical supplier, and the system design and institutional reform of NCMS should be followed according to this the basic orientation.更多还原