發(fā)布時間：2018-05-05 21:36

  本文選題：醫(yī)療保險 + 支付制度　； 參考：《復旦大學》2014年碩士論文

【摘要】：[背景]隨著中國社會經(jīng)濟發(fā)展,中國醫(yī)療衛(wèi)生保健事業(yè)已取得巨大發(fā)展,過去缺醫(yī)少藥的情況已基本改善,社會醫(yī)療保險覆蓋率和保障水平也不斷提升。但是衛(wèi)生費用快速增長的問題卻日益凸顯。2009年～2011年我國衛(wèi)生總費用增長率分別為20.7%,13.9%和21.5%,而2009年～2011年GDP增長率[4-61分別為9.2%,10.4%,9.2%,：衛(wèi)生費用三年平均增長率高出GDP三年平均增長率9.1%,衛(wèi)生費用增長速度已呈現(xiàn)高于經(jīng)濟增長速度的趨勢,有效控制衛(wèi)生費用已成為我國衛(wèi)生領域亟待解決的重要議題。科學合理的支付方式選擇是控制衛(wèi)生費用、實現(xiàn)衛(wèi)生資源有效利用的關鍵。而以定額、預付為特征的總額預付支付制度已被國內外諸多研究視作控制衛(wèi)生費用不合理增長的有效方式之一[8-10]�？傤~預付制度通過控制衛(wèi)生服務價格和衛(wèi)生服務供給量來實現(xiàn)控制衛(wèi)生服務總支出的目的。2009年以來政府發(fā)布的醫(yī)改文件顯示支付制度改革特別是總額預付改革試點是我國深化醫(yī)藥衛(wèi)生體制改革的重要內容,因此探索研究總額預付效應是必要且急迫的。國外現(xiàn)階段對總額預付的研究多關注醫(yī)保支付制度本身,例如醫(yī)�？傤~預付的支付形式、支付內容及測算方法等；關注總額預付政策實施后的最終效果,例如醫(yī)療服務費用、質量、效率、可及性及公平性等多方面變化情況,這些研究大多是根據(jù)支付方式制定者的政策目標來予以考察。而國內現(xiàn)階段對總額預付的研究多關注實施醫(yī)�？傤~預付的積極作用、存在的問題以及總額預付的影響評價,且多為案例研究。因此對總額預付效應的抽象性理論研究十分重要。[目的]在定性理論研究、數(shù)學模型構建、以及對醫(yī)療機構、醫(yī)生、患者的實證研究基礎上,系統(tǒng)探討醫(yī)療保險總額預付效應,提出相應的政策建議,為相關管理和決策提供科學參考。理論研究。基于定性理論研究內容和數(shù)學模型構建內容,應用拉格朗日函數(shù)求解醫(yī)院在總額預付限制下最優(yōu)效用函數(shù),解釋求解所得定量最優(yōu)解含義,探討醫(yī)療保險總額預付效應,提出相應的政策建議,為相關管理和決策提供科學參考。實證研究。基于現(xiàn)場調查數(shù)據(jù),對醫(yī)療機構管理者進行關鍵知情人訪談、對臨床醫(yī)生和患者進行問卷調查,考察總額預付對醫(yī)院管理者、臨床醫(yī)生、患者行為的影響,調查管理者在總額預付下策略選取、醫(yī)生對總額預付評價、總額預付實施后醫(yī)院經(jīng)濟運行情況；調查醫(yī)生在總額預付下行為策略、醫(yī)生對總額預付的評價；患者在實施總額預付醫(yī)療機構就診感受。探討總額預付實施對醫(yī)院、醫(yī)生、患者實際產(chǎn)生的影響,并探索其可能原因,提出相應政策建議,為相關管理和決策提供科學參考。[方法]理論研究。本研究采用文獻評閱方法分析總額預付的作用機制及影響,在定性理論研究基礎上構建數(shù)學模型探索效應作用方向。數(shù)學模型構建基本方法包括效用函數(shù)設計和極值求解。數(shù)學模型構建完成后,對單體醫(yī)院效用函數(shù)基礎模型、單體醫(yī)院效用函數(shù)擴展模型、醫(yī)療聯(lián)合體效用函數(shù)基礎模型、醫(yī)療聯(lián)合體效用函數(shù)擴展模型進行極值求解。實證研究。以上海市十家試點實施醫(yī)療保險總額預付的三級醫(yī)院為研究對象,調查23名醫(yī)院管理者(院長、副院長、門診辦公室主任)、400名臨床醫(yī)生、399名住院患者(住院天數(shù)7天以上)和400名門診患者。調查三級醫(yī)院應對總額預付的管理行為和臨床行為；調查三級醫(yī)院實施總額預付前后醫(yī)院的經(jīng)濟運行狀況；調查實施總額預付后患者的就診感受；調查臨床醫(yī)生和患者對總額預付的評價。對醫(yī)療機構管理者進行關鍵知情人訪談、對臨床醫(yī)生和患者進行問卷調查,考察總額預付對醫(yī)院管理者、臨床醫(yī)生、患者行為的影響。對管理者調查內容主要包括總額預付下醫(yī)院策略、對總額預付的評價、醫(yī)院經(jīng)濟運行數(shù)劇等；對醫(yī)生調查內容主要包括總額預付下行為策略、對總額預付的評價；對患者調查內容主要包括患者在實施總額預付試點的醫(yī)院就診感受。本研究的另一項實證調查數(shù)據(jù)來源于通過關鍵知情人訪談和問卷調查,結合定量與定性分析,考察全國7個省市10家三級醫(yī)院實施房顫射頻消融相關醫(yī)保管理措施情況,重點關注醫(yī)院是否實施總額預付,總額在醫(yī)院與科室問分配方式,具體執(zhí)行措施及監(jiān)管行為�，F(xiàn)場調查完畢后對質量合格的問卷采用Epidata軟件進行數(shù)據(jù)錄入,數(shù)據(jù)錄入后將數(shù)據(jù)庫導出到E xcel軟件中進行基本數(shù)據(jù)分析。其后采用stata100軟件對調查結果進行描述性統(tǒng)計分析,并對調查對象的基線變量進行影響因素分析,從而剔除偏倚因素,采用SAS軟件對調查結果進行多因素分析。[結果]實施總額預付后,單體醫(yī)院僅向醫(yī)�；颊咛峁┓⻊諘r,當實現(xiàn)單體醫(yī)院總體效用最大化時,服務質量無法達到最優(yōu)服務質量；單體醫(yī)院同時向醫(yī)保患者和自費患者提供服務時,當實現(xiàn)單體醫(yī)院總體效用最大化時,服務質量不確定性增加；醫(yī)療聯(lián)合體內部各醫(yī)院僅向醫(yī)保患者提供服務時,當實現(xiàn)醫(yī)療聯(lián)合體總體效用最大化時,服務質量無法達到最優(yōu)服務質量；醫(yī)療聯(lián)合體內部各醫(yī)院同時向醫(yī)�；颊吆妥再M患者提供服務時,當實現(xiàn)醫(yī)療聯(lián)合體總體效用最大化時,服務質量不確定性增加。[結論與建議]理論研究與實證研究均表明總額預付制度會對醫(yī)�；颊呓邮艿姆⻊召|量產(chǎn)生影響；理論研究與實證研究均表明總額預付會導致推諉醫(yī)保病人、醫(yī)療不足、將機構內部資源分配偏向自費診療、自費藥品及自費患者,從而影響醫(yī)保患者或總額預付覆蓋人群對醫(yī)療服務的可及性及其服務質量。建議需要多種精細化配套政策支持總額預付,進一步納入臨床路徑作為總額預付質量監(jiān)控機制的組成部分,進一步探索聯(lián)合體總額預付管理。
[Abstract]:[background] with the development of China's social and economic development, China has made great progress in medical and health care. In the past, the situation of lack of medicine has been basically improved, the coverage rate of social medical insurance and the level of security are also increasing. However, the problem of the rapid growth of health costs has increasingly highlighted the growth rate of total health expenses in China from.2009 to 2011. Not 20.7%, 13.9% and 21.5%, while the GDP growth rate of [4-61 from 2009 to 2011 is 9.2%, 10.4%, 9.2% respectively. The average growth rate of the health cost three years is higher than the average growth rate of GDP three years, and the growth rate of health costs has been higher than the economic growth rate. The effective control of the health expenditure has become an important problem to be solved in our health field. Issue. Scientific and reasonable choice of payment method is the key to control health costs and achieve effective use of health resources. A quota, prepaid payment system has been considered as one of the effective ways to control irrational growth of health costs at home and abroad. The [8-10]. total prepayment system is controlled by the price of health service. And the supply of health services to achieve the goal of controlling the total expenditure of health services in.2009 years since the government has issued medical reform documents show that the reform of the payment system, especially the total pre payment reform, is an important part of the deepening of the reform of the medical and health system in China. Therefore, it is necessary and urgent to explore the prepaid effect of the total amount. The study of total pre payment pays much attention to the medical insurance payment system itself, such as the form of payment in advance of the total medical insurance, the content of payment and the method of calculation, and so on; the final effect after the implementation of the total prepaid policy, such as medical service costs, quality, efficiency, accessibility and fairness, is mostly based on the payment party. At the present stage, the research on total pre payment in China pays much attention to the positive role of the pre payment of total medical insurance, the existing problems and the impact assessment of the total prepayment, and most of them are case studies. Therefore, it is very important for the abstract theory to study the total prepaid effect. On the basis of the empirical study of the medical institutions, doctors and patients, this paper systematically discusses the prepaid effect of the total medical insurance and puts forward the corresponding policy suggestions to provide scientific reference for the related management and decision-making. Theoretical research is based on the content of qualitative theory and the construction of the mathematical model and the Lagrange function is applied to solve the medical treatment. Under the total prepaid limit, the hospital has the optimal utility function, explains the meaning of the optimal solution, discusses the prepayment effect of the total medical insurance, and puts forward the corresponding policy suggestions to provide scientific reference for the related management and decision. A questionnaire survey was conducted with the patients to investigate the effects of total prepayment on hospital managers, clinicians, and patients' behavior, to investigate the total prepaid strategy selection of the managers, the total pre payment evaluation of the doctors, the economic operation of the hospital after the total advance payment, the total prepaid behavior strategy of the doctors, and the evaluation of the total prepayment by the doctors; Patients in the implementation of the total prepaid medical service experience. Explore the impact of total advance payment on hospitals, doctors, patients, and explore the possible reasons, put forward relevant policy recommendations, provide scientific reference for related management and decision-making. [method] theoretical research. This study uses literature review to analyze the total amount prepaid machine. On the basis of qualitative theory, a mathematical model is constructed to explore the direction of effect. The basic methods of constructing the mathematical model include the utility function design and the extreme value solution. After the completion of the mathematical model, the basic model of the utility function of the single hospital, the expansion model of the utility function of the single hospital and the basic model of the utility function of the medical consortium are established. An empirical study was conducted on the three level hospital of ten pilot medical insurance prepaid in Shanghai. 23 hospital managers (Dean, vice president, outpatient office director), 400 clinical doctors, 399 hospitalized patients (hospitalized days 7 days or more) and 400 were investigated. Outpatient patients. Investigate the management behavior and clinical behavior of the total amount prepaid by the three level hospitals; investigate the economic operation of the hospital before and after the total pre payment of the three level hospitals; investigate the experience of the patients after the total payment of the total prepayment; investigate the prepaid evaluation of the clinicians and patients. A questionnaire survey of clinicians and patients was conducted to investigate the impact of total prepayment on hospital managers, clinicians, and patient behavior. The main contents of the survey included the total prepaid hospital strategy, the total prepayment evaluation, the hospital economic operation, and so on. The contents of the doctor's investigation included the total prepaid behavior. The content of the survey was mainly included in the patient's experience in the implementation of the total prepaid trial. Another empirical data from this study was based on the interview and questionnaire survey of key lovers, combined with quantitative and qualitative analysis, and examined 10 three level hospitals in 7 provinces and cities to carry out RFID radiofrequency. The relevant medical insurance management measures are ablated, focusing on whether the hospital is carrying out the total prepayment, the total amount in the hospital and the Department, the specific implementation measures and supervision behavior. After the field investigation, the quality qualified questionnaire is used for data entry by Epidata software, and the database is exported to the E Xcel software after the data entry. After the analysis of the data, the stata100 software was used to analyze the survey results with descriptive statistics, and to analyze the influencing factors of the baseline variables of the subjects, so as to eliminate the bias factors and to use the SAS software to analyze the results of the survey. [results] after the total payment was prepaid, the single hospital provided service to the medical insurance patients only when the total amount of the total payment was prepaid. When the overall utility of a single hospital is maximized, the quality of service can not reach the best quality of service; when the single hospital provides the service to the medical insurance patients and the self paid patients at the same time, when the overall utility of the single hospital is realized maximization, the uncertainty of the service quality is increased; when the hospitals of the medical union body are only providing services to the medical insurance patients, When the overall utility of the Medical Federation is maximized, the quality of service can not reach the optimal quality of service; when the hospitals within the Medical Union provide services to the medical insurance patients and the self-paid patients at the same time, the uncertainty of the quality of service is added when the overall utility of the Medical Federation is maximized. [Conclusion and suggestion] theory research and empirical study Both the theoretical and empirical studies show that the total prepayment will lead to the prevarication of medical insurance patients and medical inadequacy, and the allocation of internal resources is biased towards the self cost diagnosis and treatment, the self-fee medicine and the self paid patients, which affect the medical insurance patients or the total prepaid coverage of the total population. The availability and quality of medical services and its quality of service. It is suggested that a variety of fine matching policies should be required to support total prepayment, and further integrated into the clinical path as part of the total prepaid quality monitoring mechanism, and further explore the prepaid management of the total volume of the United States.

【學位授予單位】：復旦大學
【學位級別】：碩士
【學位授予年份】：2014
【分類號】：R197.1;F842.684

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