【作者】 王欢；

【导师】 张亮；

【作者基本信息】 华中科技大学 ， 社会医学与卫生事业管理， 2009， 博士

【摘要】 研究目的在全民医保的背景下，对基本医疗保障制度中的底线公平进行理论探讨，为全民医保目标的实现及可持续发展提供相应的理论支持；通过对城镇职工基本医疗保险、城镇居民基本医疗保险和新型农村合作医疗制度的政策设计与运行效果比较，评价基本医疗保险体系中底线公平的实现情况，分析不公平形成的制度性原因，在典型地区案例分析的基础上，探寻有利于底线公平实现的保护性因素；在理论研究和实证研究的基础上，提出以底线公平为指向的全民医保目标实现策略。研究方法引入灾难性家庭卫生支出的概念，测算医保制度底线补偿水平；利用政策过程理论中的夏康斯基模型构建制度分析框架，进行多制度之间的比较，最终对制度的底线公平实现情况进行判断，并对制度差异进行制度性归因。资料来源：1．在中外文数据库以及其他相关网站以“全民医保”、“底线公平”、“医疗保险(保障)”、“公平”等词形成检索策略，完成文献检索，同时收集国家出台的三种基本医疗保险政策文件及其配套文件。2．现场资料收集。包括：(1)基本医疗保险政策文件(2)医疗保险管理数据库中参保人病历首页信息在河南省Z市，收集了2007年12月——2008年3月期间，14家定点医疗机构中的城镇职工医保患者与城镇居民医保患者的住院病历首页信息7354条，对病种进行频数分析后，选择920例冠心病(ICD10编码为125．101)患者信息。在广东省S市，收集了2008年6月——2008年12月期间，59家定点医疗机构中的综合医保、住院医保与农民工医保混合痔(ICD10编码为184．102)患者住院病历首页信息2104条。同时收集了2008年S市基本医疗保险运行情况统计报表。3．其它资料来源(1)2008年中国统计年鉴、2001-2008年国民经济和社会发展统计公报、第三次国家卫生服务调查报告、第四次国家卫生服务调查初步结果(已公布)等。(2)湖北省劳动与社会保障厅医保处关于三项医保政策比较的课题报告(内部资料)定量资料分析方法：对住院费用、个人现金自付费用以及住院天数进行描述性分析(均值、标准差计算)；对不同医保制度下的费用信息和住院天数进行单因素分析(t检验和方差分析)；对不同医保患者的就医机构分布情况进行卡方检验和对应分析。所有数据分析采用SPSS for Windows 12．0专业统计软件处理。研究结果1．在底线公平理论研究的基础上，提出了评价基本医疗保险制度底线公平的三方面要求及具体标准：首先，公平参保。有参保权利公平和参保能力公平两方面要求，即一是医保制度将所有人群覆盖；二是个人筹资所占的比例应不超过筹资总水平的50％。其次，医保制度应将提供基本医疗服务中的大病住院医疗保障作为底线目标。第三，医保制度实际补偿水平的底线标准。选择10％作为灾难性家庭卫生支出的临界值，测算出城镇基本医疗保险制度实际补偿比的底线水平是55．22％，农村基本医疗保险制度实际补偿比的底线水平为54．72％。2．在对城镇职工医保、城镇居民医保和新农合制度进行政策分析与运行效果比较后发现，三种制度在覆盖对象、筹资水平与方式、筹资主体、待遇水平等方面均有差异，且城镇居民医保与新农合较为接近，城镇职工医保与二者的差异明显。具体表现在(1)在制度安排上，三种医保制度覆盖全体人群，但是实际参保率差别较大，城镇职工医保为44．2％，城镇居民医保为12．5％，新农合为91．5％。在筹资责任的分担上，城镇居民医保中的个人筹资负担较重，超过了50％。而城镇职工医保与新农合制度中，用人单位或政府承担主要筹资责任，个人筹资负担较轻。(2)三种制度均对大病住院基本医疗提供保障，而门诊保障在三种制度中并不统一。(3)第四次国家卫生服务调查数据显示，城镇职工医疗保险住院费用补偿比最高(66．2％)，城镇居民基本医疗保险次之(49．2％)，新型农村合作医疗制度较低(34．6％)。3．在对三种制度差异进行归因分析后发现，(1)制度建立时的社会背景对底线公平实现有重要影响。城镇职工医保的建立背景决定了该制度具有提供较高保障水平的初始目标，有利于底线要求的实现。而新农合与城镇居民医保制度则将从无到有地建立制度作为主要目标，没有对保障水平提出初始目标，因而使得制度之间出现不公平。(2)城乡二元结构阻碍了城镇和农村的医保制度同步同水平发展，是造成底线不公平的原因。(3)制度理念的偏倚是造成底线不公平的另一原因。效率优先的理念被用于指导医疗保障制度，过度强调筹资的责任，以经济水平为前提对人群进行选择或排斥，没有充分体现筹资垂直公平的理念。4．对S市基本医疗保险体系(综合医保、住院医保和农民工医保制度)进行分析后发现，(1)基本医疗保险体系覆盖率达到94．28％。城镇居民和城镇职工加入同一制度，即综合医保制度。(2)三种医保制度筹资差异显著，用人单位承担了在职和退休人员的主要筹资责任，政府对城镇居民中的弱势群体参保承担主要的筹资责任，而普通城镇居民参保时个人承担主要筹资责任。(3)三种医保制度对住院和门诊均提供保障，综合医保实行个人账户，住院医保和农民工医保实行门诊统筹。(4)卫生服务利用情况不同。单病种分析结果显示，综合医保人员的住院率和平均住院天数均高于其他两种制度；综合医保人员倾向于选择三级医院和专科医院，住院医保人员倾向于选择二级医院，农民工医保人员倾向于选择一级医院。(5)次均住院费用、统筹记账费用，综合医保均高于住院医保和农民工医保，实际补偿水平三者却相差不大，综合医保82．09％，住院医保80．87％，农民工医保73．28％，且均高于城镇基本医疗保险底线补偿水平(55．22％)。农民工医保的筹资补偿效率最高，为483．67，而综合医保的筹资补偿效率为79．53。研究结论1．在全民医保目标下，底线公平指的是全体国民都有获得基本医疗保障的权利与能力，并且每个人都能获得一个基准水平的保障，这个基准的保障水平并不因个人所加入制度的差异而有所不同。2．机会公平对底线公平的实现具有重要意义。参保机会的公平要求人们有平等参保的权利，同时也要有平等参保的能力。静态来看，目前的制度安排已经将城乡不同从业情况的人群考虑在内，实现了全民有保可参。但是如果考虑到人口的流动，则在操作上带来问题，使一些人员难以参保。应参保而未参保的情况在城镇职工医保中表现明显，用人单位是主要的因素。而城乡居民主要依靠政府体现筹资责任，以提高其缴费能力。3．为了避免医疗费用产生灾难性的后果，具有一定补偿水平的基本医疗保险制度才应被视为是有效的制度。对三种医保制度的目标定位存在一定误区，即过度依赖筹资水平来定位制度的保障水平。新农合制度虽然筹资水平较低，但是农村居民对该制度提出的抗风险的要求并不明显低于城镇医保制度。因而对三种制度保障水平的定位不能简单地按照筹资水平进行排序。4．城镇职工医保的实际补偿水平达到了底线要求，而城镇居民医保和新农合的补偿水平较低，尚未达到底线要求。认为三种制度的差异是不合理差异，整个体系出现了底线不公平，需要尽快提高城镇居民医保和新农合的保障水平。5．S市在筹资差异显著的三种制度间实现了较高水平的底线公平。(1)筹资水平对补偿水平的影响并不绝对，客观存在的筹资水平差异并不是制度之间出现底线不公平的必然原因。S市的经验是，在住院医保和农民工医保中制定了强制性的社区首诊政策，通过引导人们基层就医，控制医疗费用不合理支出，提高有限基金的使用效率，从而提高低筹资医保制度的补偿水平。(2)不同制度筹资的差异性客观存在，制度之间保障能力的差异也因此客观存在。为了避免将这种制度性的差异强加于个人，应当在参保环节增加柔性调节机制，即在一定条件下允许人们根据自身情况在不同制度间作出选择，从而维护整个体系的公平。6．社会环境影响着制度目标与理念的确立。在构建和谐社会的背景下实现全民医保目标，需要明确基本医疗保险制度的定位，重塑公平理念。基本医疗保险制度不仅是一种筹资制度，也是一种社会保障制度，福利与公平是其基本属性。以人群受益的均等性为出发点的底线公平理念是基本医疗保险体系的指导理念。具体包括机会平等、医疗服务利用与医保待遇上的水平公平、筹资上的垂直公平。7．在理论分析与实证研究的基础上，提出以底线公平为指向的全民医保目标实现策略，包括：(1)增强医疗保险制度的可及性，提高医疗保险的覆盖率。扩展筹资方式，除政府补助、用人单位与个人分担外，探索慈善救助、帮困基金无息贷款等其他筹资形式；探索弹性缴费机制，平滑时间序列上部分人群的筹资不稳定性；优化简化参保程序，提高制度可及性；加强对用人单位的监督与激励，提高其参保积极性。(2)淡化个人身份，探索城乡统筹的基本医疗保险制度。在城乡差异不明显的地区，探索城镇居民医保制度和新农合制度的统筹发展模式。在经济发展水平较好的地区，可以进一步探索城镇职工医保与城镇居民医保制度的统筹发展模式。(3)增强政府责任。包括增强政府对城镇居民和农村居民参保筹资责任，缩小与城镇职工的差距；也包括增强政府在经济、社会等发展中维护社会公正的责任，提高多种公共政策的综合利贫效应，缩小贫富差距，促进社会公正。(4)构建以底线公平为指向的广泛的医疗保障体系，完善医疗救助制度，发展补充医疗保险和商业医疗保险。(5)充分发挥医疗保险制度的控费功能，引导人们到基层就诊，减少不合理医疗费用支出，提高基金补偿效率与水平，改善基本医疗保险体系的公平性。更多还原

【Abstract】 Objectives:In the context of the universal medical insurance, this study theoreticallydiscusses the baseline equality of the basic medical insurance system, in order toprovide the theoretical support for the realization of the goal of the universal medicalinsurance and its sustainable development; it evaluates the achievement of baselineequality in the basic medical insurance system and analyzes the political influentialfor the formation of inequality by comparing the system designs and operation effectsof the urban workers’ basic medical insurance, the social medical insurance for urbanresidents and the new rural cooperative medical system. On the base of case analysisfrom the typical areas, explores the protective factors that contribute to realize thebaseline equality; and then puts forwards the implementation strategies to achieve thegoal of the universal medical insurance directed to baseline equality.Methods:The baseline compensation levels of the medical system were measured by usingthe tool of household catastrophic health expenditure; the achievement of baselineequality in the system were evaluated and the institutional reasons due to systemeticdifferences were founded by comparing the multi-systems and using Shar kanskymodel to conduct the institutional analysis framework in the policy process theory.Data resources1. Literature retrieval was achieved by using the keywords as "the universalmedical insurance", "baseline equality", "medical insurance (security)" and "equality"in the Chinese Database, foreign language database as well as the other related sites,the three basic medical insurance policy documents and relative supportingdocuments were collected at the same time.2. Data collection in Z city and S city on site. Including: (1) Policy documents of the basic medical insurance system(2) Information on first page of illness cases of the insured people in themanagement database of the medical insurance.In Z city, information on first page of 7354 hospital records of patients who areeither urban workers or residents was collected in 14 appointed medical institutionsfrom December 2007 to March 2008. After the disease frequency analysis, this studychooses the information of 920 patients who suffer from coronary heart disease (theICD10 code is I25.101).In S city, patients information on first page of 2104 hospital records werecollected in 59 appointed medical institutions from June 2008 to December2008.These patients suffer from mixed hemorrhoids( the ICD10 code is I84.102) andare urban workers, urban residents or labor workers.3. Other resources(1) China Statistical Yearbook (2008), National Economic and SocialDevelopment (2001-2008), Analysis Report of National Health Services Survey in2003 and the initial results of National Health Services Survey in 2008 (published).(2) The report on the comparison of the three medical insurance systems fromthe Office of Labor and Social Security Insurance Agency in Hubei Province(unpublished).Data Analysis Methods:The descriptive analysis (calculated by means and standard deviation) wasconducted to analyze the hospitalization expenses, self-affording fees andhospitalization days; the single factor analysis (t test and ANOVA) was conducted toanalyze the cost information and the hospitalization days in different medicalinsurance systems; the Chi-square test and correspondence analysis were conducted toanalyze the medical distribution of patients in different systems. All the data wasanalyzed by using the professional statistical software of SPSS for Windows 12.0.Research Outcomes1. On the base of former research of the baseline equality theory; put forwardthree requirements and the concrete standard which can be used to evaluate thebaseline equality in basic medical security system: at first, equally subscribe toinsurance including both of the equal right and equal capability to subscribe insurance. It means, first, the medical insurance covers universal of people; second, the rate ofpersonal financing should take less the 50% of the total financing. Secondly, themedical insurance system should take the serious illness medical care as the basicgoal in basic medical service provide. Thirdly, the baseline standard of actual medicalcare compensation was caculated. Taken 10% as the critical value of catastrophicfamily pay, educed the baseline of the actual compensation rate is 55.22%, this valuein the rural area is 54.72%.2.After Comparing the basic medical insurance for urban employee(BMIUE),thebasic medical insurance for urban resident(BMIUR) and new rural cooperativemedical system (NCMS), we educed that the three systems are different in the target,financial levels and ways, the subject of financing ,treatment level ,etc. in the threesystems. Specific performance in (1) in the arrangement of the system, the threesystem capable covered the universal people, but the actual rate of subscribe intoinsurance is different, the BMIUE is 44.2%, BMIUR 12.5%, NCMS is 91.5%.on theresponsibility sharing issue, the burden on the personal financing of BMIUE isalbatross ,more than 50%. Whereas, in BMIUR and NCMS, the employer orgovernment take on the mean responsibility of financing, so the burden on private ismuch easier to take. (2)Three systems all provide the security to the serious illness,but not unity in clinical care. (3)The data from the Forth National Health ServiceSurvey suspect that the highest pay of inpatient is BMIUE(66.2%), second isBMIUR(49.2%), NCMS is the lowest, 34.6%.3. After the attribution analysis among the three systems, we could educe that, (1)the social background when the system was founded have great affection on thebaseline equality. (2)The dualistic structure of urban and rural blocks the developmentof medical care system in rural and urban area, which is also the reason of thebaseline inequitable. (3)The other reason of baseline inequitable is the bias of systemidea. The value of "efficient first" is used to guide medical care system, overemphasize financing responsibility, but not embody the idea of vertical equity infinancing.4. After analysing the basic medical insurance system in S city, we can educethat,(1)The coverage rate of basic medical insurance system in S city city reached94.28%. The urban resident and employee attended the same system, integrate medical system. (2)The difference of financing in the three systems is sharply.Employer take on the responsibility of financing for employee (incumbent andretirement) (3) Three systems provide the security to both of clinical and inpatient.Integrate medical insurance use the individual account, Inpatient and farmer workersuse clinical overall planning. (4)There are difference in health service utilize .theresult of DRGs tells that, the inpatient rate and average days of in-hospital of patientcovered by integrate insurance both higher than other two. (5)the averagehospitalization expense and overall planning account expenses of integrate health careis higher than inpatient health care and farmer worker health care ,but actualcompensate level is nearly equally .integrate medical insurance82.09%, inpatientmedical insurance 80.87%,famer worker medical insurance 73.28%,all of them higherthan the baseline compensate level of basic urban medical insurance 55.22%. theefficient of the farmer worker medical insurance is the highest,483.67, same issue onthe integrate medical insurance is 79.53.Conclusions1. On the goal of universal medical insurance, baseline equality means, theuniversal people in the country have the right and capability to be enrolled in basicmedical care. Besides, everyone could get a baseline security; the level of thisbaseline would not be different by the variety of people who attend into the system.2. The opportunity equality plays a great role in the achievement of baselineequality. Equal opportunity of health care subscribe require the people owns the sameright and capability to be enrolled in the health care. From the static aspect, the recentsystem arrangement have already considerate the different situation of the groups,make sure everybody could attend at least one health care. However, if consider thefluidity of the population, it comes the problem in implement.3. In order to avoid the catastrophic outcomes created from medical expenses,the basic medical care system with certain compensate function is considered as aneffective system. There is a specific misunderstanding among the three systems’ goallocation ,that is over depend on the level in financing capability to locate the levelof security of system. It shouldn’t taxis the security capability easily based onfinancing level.4. Actual compensate level of BMIUE have reached the baseline requirement, but the same issue on BMIUR and NCMS are lower, still not reach the baseline. Sothe differences among them are unreasonable, the baseline inequitable emerge in thewhole system, it needs to raise the level of BMIUR and NCMS as soon so possible.5. S city achieved high level baseline equality among the three systems which arevividly different in financing (1)There is no absolute effect of financing level tocompensate level, the exist financing difference is not the inevitable reason ofbaseline inequality in system. (2)There is discrepancy in financing among differentsystems, so the different support capabilities also exist in these systems. In order toavoid the system discrepancy forcing on private, keep the whole system’s equity,choice can be made among different systems according to individual’s own situationin some circumstances.6. The establishment of the concept and goal in the system was effected by thesocial environment. In order to achieve the universal medical care coverage on thebackground of harmony society construction, we should make sure the orientation ofbasic medical insurance system and rebuilt the concept of equality. The basic medicalinsurance system is not only a financing system, but also a social security system. Thefarewell and equality is its basic nature. The baseline equality concept is guideline.Including opportunity fairness on the level of medical service utilize and medical care,so as the vertical equality on financing issue.7. Based on the theoretical analysis and empirical research, put forward thestrategies for universal medical insurance stand on baseline equality as follows:(1) Reinforce the accessibility of medical insurance system; raise the coverage ofmedical insurance. Enlarge the methods of financing. Explore the other financingways like charity assistance, no tax loan fund, etc. explore flexible paymentmechanism. Optimize and simplify the process of attending insurance .reinforce thesupervision and motivation to the employer, raise its enthusiasm for attendinginsurance.(2) To consider individual identity as same. Explore the overall planning systembetween urban and rural .in the area where is no obvious difference between urbanand rural, should explore the overall planning of BMIUR and NCMS. In the goodeconomic development area, should explore the overall planning of BMIUE andBMIUR. (3) Reinforce the responsibility of government. Including the financingresponsibility for the rural and urban resident, shrink the distance to the urbanemployee. Also including reinforce government responsibility on protect justice ineconomic and society developing.(4) Construct the universal medical care system which stands on the baselineequality, fulfil the medical assistance system, and develop the supplement medicalinsurance and financial medical insurance.(5) Completely give play to the expense controller function of medical insurancesystem, lead people to seek medical service in basic medical institutions, decrease theunreasonable medical expense, raise the efficiency and the level of fund compensation,and improve the equality of basic medical insurance system.更多还原