本文選題：新型農(nóng)村合作醫(yī)療　切入點(diǎn)：補(bǔ)償方案　出處：《復(fù)旦大學(xué)》2013年碩士論文　論文類型：學(xué)位論文

【摘要】：一、研究目的與意義 新型農(nóng)村合作醫(yī)療制度(以下簡稱“新農(nóng)合”)的目標(biāo)是在保障收支平衡的基礎(chǔ)上,形成農(nóng)村居民醫(yī)療經(jīng)濟(jì)風(fēng)險合理共擔(dān)機(jī)制,最大程度地緩解因病致貧。本文研究對象華東某地(以下簡稱“A地”),從2003年開始推行該制度,在一定程度上減輕了農(nóng)民疾病經(jīng)濟(jì)負(fù)擔(dān)。但是,2008年對該地區(qū)實(shí)施的意向調(diào)查結(jié)果顯示：56.4%的人認(rèn)為當(dāng)?shù)匾虿≈仑毲闆r仍很嚴(yán)重,農(nóng)村因病致貧占貧困戶的比例大致為29.1%。近幾年,當(dāng)?shù)卣粩嗵岣咝罗r(nóng)合的籌資水平,調(diào)整住院補(bǔ)償方案。但調(diào)整后的方案能多大程度解決風(fēng)險?“因病致貧”緩解程度如何?能否實(shí)現(xiàn)“收支平衡”?若要回答這些問題,需要客觀、科學(xué)評價A地新農(nóng)合目標(biāo)的實(shí)現(xiàn)程度。 2009年開始,為了應(yīng)對醫(yī)療費(fèi)用過快增長阻礙新農(nóng)合制度可持續(xù)發(fā)展的問題,新醫(yī)改要求各地積極探索新農(nóng)合支付方式改革。2012年4月,衛(wèi)生部、國家發(fā)展改革委、財政部三部委下發(fā)了《關(guān)于推進(jìn)新型農(nóng)村合作醫(yī)療支付方式改革工作的指導(dǎo)意見》(衛(wèi)農(nóng)衛(wèi)發(fā)(2012)28號)；A地所在省也在2010年制定的新農(nóng)合支付方式改革試點(diǎn)方案中提出“力爭在2-3年內(nèi),在全省90%以上的統(tǒng)籌地區(qū)開展新農(nóng)合支付方式改革”的要求。 在這樣的政策環(huán)境下,A地需要在客觀、科學(xué)評價新農(nóng)合目標(biāo)實(shí)現(xiàn)程度的基礎(chǔ)上,結(jié)合支付方式改革的政策要求,對新農(nóng)合住院補(bǔ)償方案進(jìn)行調(diào)整。這也是本研究的目的所在。 二、材料與方法 本研究數(shù)據(jù)來是A地新農(nóng)合實(shí)施的相關(guān)數(shù)據(jù)資料,包括：2007-2012年參合、籌資等基本統(tǒng)計資料；2010-2012年政策文件、社會經(jīng)濟(jì)狀況等基本資料；2010-2011年門診補(bǔ)償數(shù)據(jù)庫；2010年到2012年前三季度住院補(bǔ)償數(shù)據(jù)庫；2011年患者住院明細(xì)數(shù)據(jù)庫等。 主要運(yùn)用了以下方法： 1、研究以政策科學(xué)理論中的簡單“前-后”對比分析法為指導(dǎo),通過比較新農(nóng)合補(bǔ)償前后各評價指標(biāo)的變化情況來評價新農(nóng)合制度的目標(biāo)實(shí)現(xiàn)程度。 2、選用規(guī)范差距分析法,將A地新農(nóng)合目標(biāo)的實(shí)際實(shí)現(xiàn)程度與新農(nóng)合“收支平衡、風(fēng)險共擔(dān)、消除因病致貧”的理想目標(biāo)進(jìn)行比較,明確該地新農(nóng)合補(bǔ)償方案的不足之處。 3、通過系統(tǒng)查閱新農(nóng)合制度評價以及按床日付費(fèi)制度相關(guān)的資料,明確本研究新農(nóng)合實(shí)施效果評價指標(biāo)和按床日支付標(biāo)準(zhǔn)的測算方法。 4、運(yùn)用聚類分析、方差分析以及回歸分析等統(tǒng)計方法輔助測算按床日支付標(biāo)準(zhǔn)。 三、研究結(jié)果 (一)A地新農(nóng)合運(yùn)行效果評價 1、一般運(yùn)行情況 A地新農(nóng)合參合率達(dá)到100%,人均籌資水平由2007年的110元提高到2012年的400元,年均增長29.46%,高于全國人均籌資水平增長率(22.01%)。2011年A地新農(nóng)合住院受益率為8.52%,住院實(shí)際補(bǔ)償比為46.16%；補(bǔ)償比例隨著醫(yī)療機(jī)構(gòu)級別的增高而依次降低。此外,2010-2012年間,A地住院總費(fèi)用以年均8.38%的速度增長；2011年次均費(fèi)用低于2010年,但2012年卻又大幅上升并超過2010年的水平。 2、2011年A地新農(nóng)合目標(biāo)實(shí)現(xiàn)程度 2.1基金基本達(dá)到收支平衡 A地新農(nóng)合資金結(jié)余率為-1.44%,基本處于相對平衡的范圍內(nèi)。 2.2一定程度上降低了就醫(yī)經(jīng)濟(jì)風(fēng)險,但未重點(diǎn)關(guān)注高風(fēng)險人群 人群就醫(yī)經(jīng)濟(jì)風(fēng)險相對危險度(RR)由11.84降至6.66,降幅為43.75%。其中,住院人群的RR下降幅度為46.16%。但是,補(bǔ)償前RR最大值為207.86,補(bǔ)償后RR最大值仍達(dá)113.40；住院費(fèi)用超過最大支付能力線的人群RR下降幅度并未高于其他低費(fèi)用水平人群。這提示A地的補(bǔ)償方案沒有重點(diǎn)關(guān)注高風(fēng)險人群。 2.3一定程度上緩解了因病致貧,但仍不理想 A地新農(nóng)合補(bǔ)償前農(nóng)村居民的因病致貧率為0.83%,補(bǔ)償后為0.35%,下降了58.07%；補(bǔ)償前因病致貧總?cè)笨跒?,083.37萬元,補(bǔ)償后為1,578.99萬元,下降了74.04%,可見A地在一定程度上緩解了因病致貧,但距離消除因病致貧的目標(biāo)還有較大差距。 (二)A地按床日支付標(biāo)準(zhǔn) 按床日付費(fèi)制度實(shí)施的關(guān)鍵是支付標(biāo)準(zhǔn)的制定�？紤]到醫(yī)療費(fèi)用跟疾病嚴(yán)重程度、治療方式以及患者年齡等因素密切相關(guān),本研究將患者分為重癥病人、手術(shù)病人、兒科病人以及普通病人四大類；由于患者住院后不同時期、不同護(hù)理級別的醫(yī)療費(fèi)用也有明顯差距,所以需要對病程進(jìn)行分段,將重癥病人按護(hù)理等級(包括特級、一、二、三級護(hù)理)進(jìn)行分段,將手術(shù)病人按照術(shù)前、中、后進(jìn)行分段,而對于兒科病人和普通病人則按天數(shù)進(jìn)行分段；此外,不同級別的醫(yī)療機(jī)構(gòu)醫(yī)療費(fèi)用差異較大,將醫(yī)療機(jī)構(gòu)分為鄉(xiāng)鎮(zhèn)級、區(qū)級、市級三個級別,得出A地2011年各級別醫(yī)療機(jī)構(gòu)各類型病人各疾病分段的實(shí)際日均費(fèi)用。 在此基礎(chǔ)上,綜合考慮不合理醫(yī)療費(fèi)用比例、醫(yī)療產(chǎn)品價格指數(shù),測算出了2013年A地的日均費(fèi)用標(biāo)準(zhǔn)。為了盡量減小政策調(diào)整帶來的震蕩,本研究參照A地原先的補(bǔ)償比例,測算出了2013年A地的按床日支付標(biāo)準(zhǔn)。最后,進(jìn)一步針對按床日付費(fèi)制的缺陷,提出了A地新農(nóng)合管理機(jī)構(gòu)對醫(yī)療機(jī)構(gòu)進(jìn)行監(jiān)督考核的相關(guān)策略建議。 (三)A地二次補(bǔ)償方案 考慮到按床日支付僅針對每次的醫(yī)療費(fèi)用進(jìn)行補(bǔ)償,未能關(guān)注全年累計自付醫(yī)療費(fèi)用給農(nóng)村居民造成的經(jīng)濟(jì)負(fù)擔(dān),因此,本研究在此基礎(chǔ)上,為A地研制了二次補(bǔ)償方案。研究首先測量按床日支付標(biāo)準(zhǔn)補(bǔ)償后農(nóng)民就醫(yī)經(jīng)濟(jì)風(fēng)險分布和因病致貧狀況,明確了消除因病致貧風(fēng)險所需的籌資額,判斷出A地用于二次補(bǔ)償?shù)幕鹂梢赃_(dá)到消除因病致貧的目標(biāo)；其次,考慮到二次補(bǔ)償方案重點(diǎn)關(guān)注高風(fēng)險人群,確定其風(fēng)險保障性質(zhì)為風(fēng)險型。 為控制不合理的需求增長,二次補(bǔ)償方案考慮共付制,即包含起付線、封頂線以及補(bǔ)償比等關(guān)鍵要素。由于消除因病致貧是二次補(bǔ)償方案的首要目標(biāo),理論上超過最大支付能力的醫(yī)療費(fèi)用都應(yīng)采用最高比例報銷,但為了避免收入對醫(yī)療消費(fèi)的直接效應(yīng)給新農(nóng)合制度所帶來的負(fù)面影響,最終采用了多段遞減式補(bǔ)償?shù)哪Ｊ健?(四)A地調(diào)整后住院補(bǔ)償方案的預(yù)評價 本研究將二次補(bǔ)償方案與按床日支付方案結(jié)合,最終形成A地2013年定點(diǎn)醫(yī)療機(jī)構(gòu)住院補(bǔ)償方案,并對其新農(nóng)合目標(biāo)實(shí)現(xiàn)程度進(jìn)行了預(yù)評價,結(jié)果為：新農(nóng)合基金將結(jié)余-0.29%；人群平均就醫(yī)經(jīng)濟(jì)風(fēng)險RR將下降53.10%,補(bǔ)償前RR最大值為228.83,補(bǔ)償后RR最大值將降為63.95,且最大支付能力以上費(fèi)用水平RR降低幅度將明顯高于其他費(fèi)用水平,最高預(yù)計達(dá)72.05%；因病致貧率將下降87.50%,因病致貧總?cè)笨趯p小97.97%,基本消除因病致貧。 四、研究創(chuàng)新 1、本研究從理論和實(shí)踐應(yīng)用的角度展示了新農(nóng)合補(bǔ)償方案評價和調(diào)整的全過程,針對現(xiàn)階段新農(nóng)合存在關(guān)鍵難題給予明確的解答,具有一定的指導(dǎo)價值。 2、本研究探索了將控制醫(yī)療費(fèi)用過快增長和針對性實(shí)現(xiàn)新農(nóng)合制度目標(biāo)綜合考慮來調(diào)整新農(nóng)合住院補(bǔ)償方案的理念,以確保新農(nóng)合支付方式改革穩(wěn)定進(jìn)行的同時實(shí)現(xiàn)制度的長遠(yuǎn)目標(biāo)。
[Abstract]:First, the purpose and significance of the study
The new rural cooperative medical system (NCMS) goal is to guarantee the balance of payments based on the formation of medical economic risk of rural residents reasonable sharing mechanism, greatly alleviating the poverty due to illness. This thesis focuses on a region of East China (hereinafter referred to as "A"), from the beginning of 2003 the implementation of the system, to a certain degree to alleviate the financial burden of the disease. However, on 2008 the implementation of the survey area shows that 56.4% of people think that the local poverty situation is still very serious, rural poverty accounted for the proportion of poor households is approximately 29.1%. in recent years, the local government to improve the level of financing of NCMS, adjust the hospitalization compensation. But the adjustment the scheme can greatly solve the risk? "Pccd" relief degree? How to achieve "balance"? To answer these questions, you need an objective, scientific Evaluate the realization degree of the new CMS target in A.
The beginning of 2009, in order to cope with the excessive growth of medical costs hinder the sustainable development of new rural cooperative medical system, the new health care reform urged all localities to actively explore NCMS payment reform in.2012 in April, the Ministry of health, the national development and Reform Commission, the Ministry of Finance issued three ministries "on the promotion of new rural cooperative medical payment reform work guidance (> Weinong Wei (2012) No. 28); A is also formulated in 2010 NCMS payment reform program proposed" strive to 2-3 years to carry out the requirements of the NCMS payment reform "of the whole region in the province more than 90%.
In such a policy environment, A needs to objectively and scientifically evaluate the realization degree of NRCMS. Combined with the policy requirements of the payment reform, we should adjust the inpatient reimbursement program of the new rural cooperative medical system, which is also the purpose of this research.
Two, materials and methods
The data of this study is to the related data, the A implementation of the system include: 2007-2012 years of participation, the basic statistical data of financing; 2010-2012 years of policy documents, social and economic conditions and other basic information; 2010-2011 years of outpatient compensation database; 2010 to 2012 before the three quarter of 2011 in hospital compensation database; patients in detail database.
The main use of the following methods:
1, guided by the simple "front to back" comparative analysis method in policy science theory, we evaluated the target realization degree of the new rural cooperative medical system through comparing the changes of the evaluation indicators before and after the compensation of the new rural cooperative medical system.
2, the analysis specification gap, the actual A system the degree of realizing the goal of new rural cooperative medical system and the balance of payments, risk sharing, compare the ideal goal of eliminating poverty due to illness, clear the compensation project deficiencies.
3, through the systematic review of the new rural cooperative medical system evaluation and the data related to the daily payment system, we can make clear the evaluation index of the new rural cooperative medical system implementation and the calculation method of the payment standard according to the bed day.
4, using statistical methods such as cluster analysis, variance analysis and regression analysis to calculate the standard of payment according to the bed day.
Three, the results of the study
(1) evaluation of the operation effect of A
1, general operation
A NCMS participation rate reached 100%, the per capita funding level increased from 110 yuan in 2007 to 400 yuan in 2012, an average annual growth rate of 29.46%, higher than the national growth rate of per capita funding level (22.01%).2011 A NCMS hospitalization rate was 8.52%, in the actual compensation ratio is 46.16%; the compensation ratio increased with the level of medical institutions which in turn reduces. In addition, 2010-2012 years, A to the total hospitalization expenses of the average annual growth rate of 8.38% in 2011; the average expense is lower than in 2010, but in 2012 it rose sharply and exceeded the level in 2010.
The realization degree of the target of new agricultural cooperation in the past 22011 years in A
2.1 funds basically achieve balance of payments
The fund surplus rate of nncms in A is -1.44%, which is basically in the range of relative balance.
2.2 to a certain extent, the economic risk of medical treatment has been reduced, but the high risk population is not focused on.
The crowd medical risks relative risk (RR) from 11.84 to 6.66, a decline of 43.75%. among the hospitalized population decreased by RR 46.16%. but before compensation RR maximum value is 207.86, the maximum compensation after RR still amounted to 113.40; hospitalization expenses exceeds the maximum capacity to pay line group RR decline was not higher than that of other low the cost level of population. It suggests that the A compensation scheme to not focus on high risk population.
2.3 to some extent alleviate poverty due to illness, but still not ideal
A compensation before the rural residents of the poverty rate is 0.83%, after compensation for 0.35%, a decrease of 58.07%; the total compensation before the poverty gap was 60 million 833 thousand and 700 yuan, compensation for 15 million 789 thousand and 900 yuan, down 74.04%, visible A to some extent alleviate poverty due to illness, but there is a large gap between the distance to eliminate poverty the target.
(two) A according to the bed day payment standard
The per diem payment key implementation of the system is to develop payment standards. Considering the medical expenses with the severity of the disease, treatment and patient age and other factors are closely related, in this study, patients were divided into patients, surgery, pediatric patients and normal patients in four categories; due to different periods of hospitalization after different nursing level the medical expenses have significant difference, so the need for a course are segmented according to nursing patients with severe symptoms (including grade A, grade two, grade three, nursing) segments will patients according to preoperative, and after segmentation for pediatric patients and normal patients according to the number of days in the section; medical expenses between medical organizations of different levels in large medical institutions should be divided into the township level, district level, municipal level three, the patients with various types of medical institutions A 2011 all levels of segmented real disease The average daily cost.
On this basis, considering the unreasonable proportion of medical expenditure, medical products price index, calculated the average daily cost of a standard A in 2013. In order to minimize the shock of policy adjustment, the proportion of compensation to A research according to the original estimate, 2013 A per diem payment standard. Finally, for further per diem system defects, put forward the A management mechanism of supervision and appraisal suggestions on the strategies of medical institutions.
(three) the two compensation scheme for A
In consideration of the payment according to the bed, only to compensate for each medical expenses, failed to pay attention to the annual total pay medical expenses for rural residents caused by the economic burden, therefore, on this basis, A developed two times compensation scheme. Firstly, measurement payment standard compensation according to the bed, after farmers seeking economic risk distribution and the poverty situation, clear the amount of funding poverty elimination risk required, judging from A for two times the compensation fund can eliminate poverty targets; secondly, taking into account the two compensation schemes focus on high risk population, determine the nature of risk protection as the risk.
In order to control the growth of the unreasonable demand, two times the compensation scheme considering the co payment system, which includes the pay line, cap line and the compensation ratio of key elements. Due to the elimination of poverty is the primary goal of two times compensation scheme, theoretically exceeds the maximum capacity to pay medical expenses should be used on the highest proportion of reimbursement, but in order to avoid the negative impact of the direct effect of income on medical consumption brought by the new rural cooperative medical system, the multi regressive compensation model.
(four) pre evaluation of compensation scheme for hospitalized patients after A adjustment
This study will be two times the compensation scheme and the per diem payment scheme with A was formed in 2013 designated medical institutions hospitalization reimbursement scheme, and the new goal attainment in the pre evaluation, results are as follows: the new rural cooperative fund balances will be -0.29%; the average hospitalization economic risk RR population will decline by 53.10%, before the maximum compensation RR 228.83, after the compensation of the maximum value of RR will be reduced to 63.95, and above the maximum capacity to pay expenses rate will decrease the level of RR was significantly higher than that in other expenses, the highest is expected to reach 72.05%; poverty rate will decline by 87.50%, the total poverty gap will be reduced to 97.97% and eliminate poverty.
Four, research innovation
1, this research shows the whole process of evaluation and adjustment of the new rural cooperative medical compensation scheme from the perspective of theory and practice. It has certain guiding value for solving the key problems in the new rural cooperative medical system at the present stage.
2, this study explored the idea of adjusting the reimbursement program of NRCMS with the aim of controlling the excessive growth of medical costs and implementing the target of NRCMS, so as to ensure the stable reform of the NCMS payment mode and achieve the long-term goal of the system.

【學(xué)位授予單位】：復(fù)旦大學(xué)
【學(xué)位級別】：碩士
【學(xué)位授予年份】：2013
【分類號】：R197.1;F842.684;F323.89

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