【作者】 李新华；

【导师】 谭红专；

【作者基本信息】 中南大学 ， 社会医学与卫生事业管理， 2010， 博士

【摘要】 目的通过对湖南省新型农村合作医疗(新农合)制度现有运行情况进行全面调查,掌握相关资料,深入分析湖南省新型农村合作医疗现状、存在问题、居民健康状况、住院费用及相关影响因素,探讨解决新型农村合作医疗工作中存在问题的方法,建立合理的筹资与补偿方案,为合理配置湖南省卫生资源,促进新型农村合作医疗健康发展提供依据。方法采用多级整群随机抽样方法,从湖南省11个新农合试点地区中的每一个地区随机抽取一个县(市、区)构成研究样本。对于抽样县参合农民住院基本情况、新农合基金补助受益情况以及补偿方案的设计等采用数据分析方法。具体如下：(1)对样本人群的人口学特征、住院基本情况等采用描述性分析,两组或多组计数资料的比较采用卡方检验；(2)应用单因素及有序多分类的logistic回归模型分析参合农民住院费用及其影响因素；(3)2006年湖南省抽样县新农合基金运行情况,如筹资、基金使用、补助收益、基金流向等方面采用描述性分析方法；(4)基于上述研究并结合目前新农合政策,设计合理的费用补偿方案,建立费用补偿测算模型,并进行实证研究。结果2006年湖南省建立新型农村合作医疗制度的县(市、区)共有43个,覆盖农村人口2463.5万人；参加新农合的农民达1857.2万人,平均参合率为75.39%。抽取11个样本县(市),合计参合人数694376人,其中男性365014人,占总人数的52.57%,女性329362人,占47.43%。(1)住院服务情况分析：在定点医疗机构的平均住院率为7.02%,其中桑植、双牌、会同、石门、岳阳的住院率较高,分别为11.93%、10.57%、8.80%、8.26%、7.23%。参合农民中女性的住院率高于男性,分别为8.01%和6.13%；不同年龄的参合农民住院率呈“V”字型分布,15-岁组的住院率最低为4.29%,60岁以上组住院率最高为12.26%；疾病别住院率前五位的疾病为呼吸系统疾病(22.91%)、消化系统疾病(16.77%)、泌尿生殖系统疾病(10.20%)、中毒及损伤(9.60%)、循环系统疾病(8.44%)；住院病人的流向分析结果显示60.67%的参合农民在乡镇级别的医疗机构住院。(2)新农合住院费用分析：住院费用的单因素和有序多分类的logistic回归分析显示,性别、年龄、住院天数、医疗机构的级别、地区经济水平、病种六个变量对住院费用均有影响。其中男性的次均住院费用高于女性；次均住院费用随着年龄的增加而增加：小于15岁组的次均住院费用最低为1038.12元,60岁以上组次均住院费用最高为2017.17元；住院天数的长短与住院费用成正相关,住院天数越长,次均住院费用越高；医疗机构级别越高次均住院费用越高：省级定点医疗机构次均住院费用最高为9070.67元,乡镇医疗机构的次均住院费用最低为781.52元；住院费用与地区经济发展水平相关,经济发展水平高的地区次均住院费用最高2311.20元,欠发达地区次均住院费用最低1249.16元；有序多分类的logistic回归分析结果显示：肿瘤的次均住院费用最高,先天异常,筛检、术后放化疗和康复,神经与行为障碍,围生期疾病等的次均住院费用次之,呼吸系统疾病,耳和乳突疾病,皮肤和皮下组织疾病次均住院费用最低。(3)2006年湖南省抽样县市新农合基金运行情况：筹集基金总额3308.60万元,其中参合农民个人缴费694.38万元,占基金总额的20.99%,各级财政补助资金2614.23万元,占基金总额的79.01%。用于住院补助的基金总额为2510.95万元,占筹集基金总额的75.89%。共补助住院48500人次,受益面为6.98%,其中桑植、双牌、会同、石门、岳阳5个县的受益面高于全省平均水平,桑植和双牌的受益面最高,分别为11.87%和10.52%；而望城、花垣、炎陵、湘乡、桂阳和常宁6个县市低于全省平均水平,最低的是常宁,其受益面仅为3.19%。参合农民住院实际花费8344.22万元,补助资金为2510.95万元；次均住院费用为1711.25元,次均可报费用为1492.61元,次均补助费用为514.95元,全省平均受益度为30.09%。其中桑植、石门、常宁、花垣、会同5县市的受益度高于全省平均水平,另外6个县市则低于全省平均水平。受益度最高的和受益度最低的县市分别是花垣(38.68%)和湘乡(22.16%)。2006年全省住院补助人次主要集中在乡级和县级,县乡两级机构占补助人次数的86.99%。与此相对应,住院补助资金流向县级和乡级的比例亦较大,但不成比例。乡级医疗机构住院补助人次占总补助人次的60.63%,但资金流向比例只为39.32%；县级医疗机构住院补助人次占总补助人次的26.36%,但资金流向比例达35.13%。各县市补助人次和补助资金流向存在一定差异,部分县市住院人次流向省级和市级的比例较大。(4)费用补偿方案的设计：基于“起付线+共同保险+封顶线”的混合支付体制,根据合作医疗基金分配测算的基本原理,即“以收定支、收支平衡”,重点考虑参合率、住院统筹基金总量、住院率、各级次均住院费用、病员流向结构及疾病对家庭和对社会的危害等因素,设计了四套补偿方案。一级、二级和三级医疗机构的起付线分别是100元、300元和500元,封顶线均为6万元。不同级别医疗机构不同病种设定不同的补偿比例。通过实证研究和评价,结果显示方案2的效果最好,住院实际补偿率达到49.68%,补偿资金达到住院统筹基金的99.44%。方案2的具体情况是：肿瘤、传染病、住院分娩、次均住院费用高(≥1000元)的病种、次均住院费用低(<1000元)的病种在一级医疗机构的补偿比率分别为85%、80%、55%、75%、70%,在二级医疗机构分别为80%、75%、65%、70%、65%,在三级医疗机构分别为70%、65%、70%、60%、55%。(5)建立了方便实用的补偿费用测算模型结论(1)参合农民的住院服务利用水平较高,育龄期妇女、15岁以下和60岁以上的参合农民是住院卫生服务的重点人群；参合农民住院原因以感染性疾病为主(呼吸系统、消化系统、泌尿系统),但同时慢性非传染病(循环系统疾病)的患病率明显增加。(2)性别、年龄、住院天数、医疗机构的级别、地区经济水平和病种是住院费用的影响因素。(3)湖南省新型农村合作医疗自2003年试点以来参合率逐年提高,但参合积极性还有待进一步提高。筹资水平偏低,基金使用率稍低于政策规定要求,部分县市基金沉淀过多。受益面窄,多数参合农民不能受益；补偿率偏低,农民受益度不高；补助水平不平衡,多数县市合作医疗减轻农民医疗负担的作用和效益还没有充分发挥出来。但补助人次流向和补助资金分布总体上比较合理,主要集中在乡、县级医疗机构。(4)针对新农合运行现状,因地制宜的探讨科学合理的费用补偿方案,制定合理的起付线、封顶线和不同级别医疗机构、不同病种的补偿比例,能充分发挥合作医疗基金的补偿效益,又能促使医疗卫生资源的合理利用和分配。通过费用补助减轻农民因病就医的费用负担至关重要。(5)本研究建立的补偿费用测算模型是方便和实用的。实证研究证实,在现有的筹资水平下,本研究提出的补偿方案2是目前最科学和合理的方案,能有效发挥合作医疗基金的保障作用。更多还原

【Abstract】 ObjectivesAn investigation on the operation of the New Rural Cooperative Medical System (NRCMS) in Hunan was made to obtain relevant data and further analyze the status including existing problems of NRCMS in Hunan, rural residents’health status, hospitalization expenses and the influencing factors in order to explore the possible solutions for the problems in NRCMS and provide the basis for reasonable allocation of the health resources in Hunan to promote the sustainable development of NRCMS.MethodsWith multistage clusters random sampling, one county (city and district) from each of 11 prefectures in Hunan where NRCMS pilot programs were implemented was randomly selected to build the study sample. Data analysis was used for the study of NRCMS participants’ hospitalization, reimbursements by the NRCMS fund and design of the reimbursement scheme. Detailed information is as follows:1) Descriptive analysis was used for the demographical data and hospitalization of the sample and chi-square test was used for comparison of the quantitative data of two and more groups; 2) single factor and ordinal multi-category logistic regression model was used for analysis of NRCMS participants’ hospitalization expenses and the influencing factors; 3) descriptive analysis was used for the operation of the NRCMS fund in the sampled counties in Hunan in 2006, including financing, fund utilization and reimbursement and fund distribution; 4) based on the above study and in combination of the NRCMS policy a reasonable expense reimbursement scheme was designed and a model of expense reimbursement calculation was established. Meanwhile an empirical study on them was made.ResultsNRCMS was implemented in forty-three counties (cities and districts) in Hunan, covering a population of about 24,635,000 rural residents, among which about 18,572,000 joined in NRCMS and the average participation rate was 75.39%. Eleven counties (cities and districts) were chosen with a total of 694,376 participants, among which 365,014 (52.57%) were men and 329,362 (47.43%) women.1) Analysis of hospitalization service. The average hospitalization rate in the NRCMS contracted hospitals was 7.02%; the hospitalization rates in Sangzhi, Shuangpai, Huitong, Shimen and Yueyang were high:11.93%、10.57%、.80%、.26%、7.23%, respectively; women participants’hospitalization rate was higher than men’s:8.01% and 6.13%, respectively; The distribution of the hospitalization rate of the participants at different age was like the letter V:the hospitalization rate of the group of 15-29 years old was the lowest (4.29%) and of the group of aged 60 and above was highest (12.96%); the top five diseases of the hospitalization rate were respiratory system diseases (22.91%), digestive system diseases (16.77%), urinary and reproductive system diseases (10.20%), poisoning and injury (9.6%), circulation system diseases (8.44%); The analysis of the distribution of hospitalized patients showed that 67.67% of the NRCMS participants were hospitalized in township medical institutions.2) Analysis of hospitalization expense. The analysis of hospitalization expenses through single factor and ordinal multi-categroy logistic regression analysis showed that all six variables including gender, age, days of hospitalization, level of hospitals, economic level of the counties and types of diseases influenced hospitalization expenses. The average hospitalization expense per visit for men was higher than that for women; The hospitalization expense increased as age increased:The hospitalization expense per visit for the group of the age below 15 was the lowest:1038.12 yuan while the hospitalization expense per visit for the group of above 60 years old was highest:2017.17 yuan; The duration of hospitalization was positively correlated with hospitalization expense:the longer the duration of hospitalization was, the higher the hospitalization expense per visit was; the higher the level of the hospitals were, the higher the hospitalization expense per visit were; hospitalization expense per visit in the contracted provincial hospitals was highest:9070.67 yuan, and hospitalization expense per visit in township hospitals was lowest:781.52 yuan; hospitalization expense was related with the economic development level in the county:hospitalization expense per visit in the county of the high economic development level was highest: 2311.20 yuan, the hospitalization expense per visit in the county of the low economic development level was lowest:1249.16 yuan. Ordinal multi-categroy logistic regression analysis showed that hospitalization expense per visit for tumor was highest, that for congenital anomaly, screening and postoperative radio chemotherapy and rehabilitation, neural and behavioral disorder, and perinatal diseases took the second place, that forrespiratory system diseases, ear and mastoid diseases,dermatological and subcutaneous tissue diseases was lowest.3) Operation of NRCMS in the sampled counties (cities) in Hunan in 2006. The total of raised fund was 33,086,000 yuan, among which NRCMS participants made contribution of 6,943,800 yuan,20.9% of the total fund, and public finance at all levels paid 26,142,300 yuan as allowance,79.01% of the total fund. The total of fund used for hospitalization reimbursement was 25,109,500 yuan, which is 75.89% of the total of raised fund, and 48,500 visits were reimbursed for hospitalization expense. The beneficiary rate was 6.98%. The beneficiary rates of Sangzhi, Shuangpai, Huitong, Shimen, and Yueyang were higher than the average provincial beneficiary rate. The beneficiary rates of Sangzhi and Shuanpai were highest:11.87% and 10.52%, respectively; the beneficiary rates of Wangcheng, Huayuan, Yanling, Xiangxiang, Guiyang and Changning were lower than the average provincial beneficiary rate; the beneficiary rate of Changning was lowest:3.19%. The actual hospitalization expense that the NRCMS participants paid was 83,442,200 yuan, reimbursement was 25,109,500 yuan; hospitalization expense per visit was 1711.25 yuan, and the expense per visit that could be reimbursed was 1492.61 yuan, reimbursement for each visit was 514.95 yuan, and the average provincial reimbursement rate was 30.09%. The reimbursement rates of Sangzhi, Shimen, Changning, Huayuan, and Huitong were higher than the average provincial reimbursement rate while the reimbursement rates of the other 6 counties (cities) were lower than the average provincial reimbursement rate. The highest and the lowest reimbursement rates were that of Huayuan (38.68%) and that of Xiangxiang (22.16%), respectively. In the year 2006 hospitalization reimbursement mainly concentrated on the hospitalizations in township and county hospitals that consisted of 86.99% of the reimbursed visits. Correspondingly, the proportion of the reimbursement for hospitalization in township and county hospitals was fairly big, but disproportionate. The reimbursement for hospitalization in the township hospitals consisted of 60.63% of the total reimbursed visits, but the proportion of reimbursement distribution was 39.32%. The reimbursement for hospitalization in county hospitals consisted of 26.36% of the total reimbursed visits, but the proportion of reimbursement distribution was 35.13%. There were difference among reimbursed visits and reimbursement distribution in the counties (cities) and the proportion of some counties’hospitalizations that went to prefecture level and provincial hospitals was fairly big.4) Design of expense reimbursement scheme. According to the basic principles of the calculation of the NRCMS fund, that is, "payout depends on income and balance of payments", and based on the payment system of "deductible coverage plus coinsurance and ceiling" major considerations was given to NRCMS participation rate, the total of hospitalization co-ordination fund, rate of hospitalization, hospitalization expense per visit in the hospitals at all levels, patient distribution, and harm done to family and society by diseases and other factors. Four reimbursement schemes were designed. The deductible coverage for the medical institutions at the first, second and third levels were 100 yuan,300 yuan, and 500 yuan, respectively and the ceiling for all was 60,000 yuan. A specific proportion of reimbursement for the expenses for specific diseases in the hospitals at different level was designed. The results of the empirical study and evaluation showed that the 2nd scheme was the best:the rate of hospitalization reimbursement was actually 49.68% and the reimbursed expense was 99.44% of the hospitalization fund. The 2nd reimbursement scheme was as follows: the rate of reimbursement for the hospitalization expense for tumor, infectious diseases, delivery, diseases with average hospitalization expense per visit of one thousand yuan or more, and diseases with average hospitalization expense per visit of less than one thousand yuan were 85%,80%,55%,75% and 70%, respectively in the hospitals at the first level; 80%,75%,65%,70%and 65%, respectively in the hospitals at the second level; 70%,65%,70%, 60% and 55%, respectively in the hospitals at the third level.5) A convenient and practical model of expense reimbursement calculation was made:M=N×ΣPij×Eij×Rij×(1+F) (i=1,2,3,j=1,2,3,4,5). ConclusionsThe following conclusions have been drawn in the study:1) The utilization level of hospitalization service by NRCMS participants was high, and women of childbearing age, and participants of 15 years and below, and 60 years and above were the key population of hospitalization service; the majority of the diseases for which the NRCMS participants were hospitalized were infectious diseases (of respiratory system, digestive system and urological system). But at the same time prevalence of chronic non-infectious diseases increased obviously.2) The influencing factors for hospitalization expense included gender, age, days of hospitalization, level of hospitals, economic level, and type of disease.3) The participation rate of NRCMS in Hunan increased annually ever since the pilot program of NRCMS started in Hunan in 2003. The enthusiasm for participation in NRCMS needs to be further promoted. The level of financing was low. The rate of use of NRCMS fund was slightly lower than that required in the policy and too much surplus was left over. The majority of the NRCMS participants did not benefit from the fund; the rate of reimbursement was low; the level of reimbursement was not balanced so that the role and effect NRCMS in many counties (cities and districts) played in reducing medical burden was not achieved. However, the reimbursed visits to hospitals and distribution of reimbursement were generally reasonable, mainly concentrated on township and county medical institutions.4) To explore a scientific and reasonable expense reimbursement scheme according to the conditions in specific counties (cities and districts), to set up deductible coverage, ceiling and the proportion of reimbursement for hospitals at different levels and for specific type of diseases can help maximize the reimbursement effect of NRCMS and facilitate the reasonable use and allocation of health resources. It is vital that the burden of farmers’medical expense be reduced through reimbursement.5) The model of expense reimbursement calculation made in this study was convenient and practical. It was proved in the empirical study that the 2nd reimbursement scheme established in the study was most scientific and reasonable so far for the present level of NRCMS financing.更多还原