本文選題：醫(yī)療保險 + 醫(yī)療服務(wù)需求　； 參考：《南開大學(xué)》2013年博士論文

【摘要】：為建立“人人享有基本醫(yī)療保障”制度,保證每個人不分地域、民族、年齡、性別、職業(yè)、收入水平,都能公平獲得基本醫(yī)療衛(wèi)生服務(wù),實現(xiàn)“人人享有基本醫(yī)療衛(wèi)生服務(wù)”的醫(yī)療衛(wèi)生體系,我國的醫(yī)療衛(wèi)生體制不斷進行改革和完善。當(dāng)前,隨著我國基本醫(yī)療保險覆蓋范圍的擴大,覆蓋城鄉(xiāng)的全民醫(yī)保體系已經(jīng)基本形成。目前我國的基本醫(yī)療保障制度是以新型農(nóng)村合作醫(yī)療、城鎮(zhèn)居民基本醫(yī)療保險、城鎮(zhèn)職工基本醫(yī)療保險和城鄉(xiāng)醫(yī)療救助為主體,分別覆蓋農(nóng)村人口、城鎮(zhèn)非就業(yè)人口、城鎮(zhèn)就業(yè)人口和城鄉(xiāng)困難人群,解決了部分人群醫(yī)療保險缺失的不公平問題。但是,另一方面,制度本身的設(shè)計隨著實施的進一步深化也逐漸的暴露出諸多問題。由于城鄉(xiāng)二元結(jié)構(gòu)使得居民在健康水平、醫(yī)療服務(wù)的可及性、可得性存在較大差距。而不同醫(yī)療保險制度提供經(jīng)濟風(fēng)險保護時,在醫(yī)保繳費標(biāo)準(zhǔn)、待遇水平、保障范圍、報銷比例等設(shè)計方面方面存在較大差異。這有可能進一步拉大城鄉(xiāng)居民對醫(yī)療服務(wù)的使用和需求差距,進而可能導(dǎo)致城鄉(xiāng)居民健康水平更大差距。同時,基本醫(yī)療保險制度的新農(nóng)合、城職保和城居保三大主體制度：新型農(nóng)村合作醫(yī)療、城鎮(zhèn)居民基本醫(yī)療保險和城鎮(zhèn)職工基本醫(yī)療保險存在著制度交叉；不同的管理機構(gòu)和管理體制造成了制度運行的低效率。 本文正是基于以上研究背景,綜合運用微觀經(jīng)濟學(xué)、保險經(jīng)濟學(xué)、衛(wèi)生經(jīng)濟學(xué)、計量經(jīng)濟學(xué)等方法,建立在醫(yī)療服務(wù)需求理論與醫(yī)療保險基本理論基礎(chǔ)上,一方面,從宏觀視角,描述性分析國際和國內(nèi)不同醫(yī)療保險制度模式實施效果；另一方面,從微觀視角,實證檢驗包括商業(yè)醫(yī)療保險在內(nèi)的、不同類型的基本醫(yī)療保險對我國城鄉(xiāng)居民醫(yī)療服務(wù)需求和使用的影響差異。 本文首先運用微觀經(jīng)濟學(xué)、保險經(jīng)濟學(xué)和衛(wèi)生經(jīng)濟學(xué)基本理論,闡述了健康與醫(yī)療服務(wù)需求理論和醫(yī)療保險需求理論以及醫(yī)療保險對醫(yī)療服務(wù)需求的影響理論,然后分別從國外和國內(nèi)研究文獻(xiàn)中回顧總結(jié)醫(yī)療保險對治療行為選擇和醫(yī)療服務(wù)需求支出影響的實證研究結(jié)果。本文研究的重點是,利用2008年“中國健康與養(yǎng)老追蹤調(diào)查(CHARLS)"截面數(shù)據(jù),以45周歲以上的中老年人為研究對象,采用不同的計量方法,以新型農(nóng)村合作醫(yī)療為參照組,估計不同類型的醫(yī)療保險包括：城鎮(zhèn)職工基本醫(yī)療保險、城鎮(zhèn)居民基本醫(yī)療保險、公費醫(yī)療和商業(yè)醫(yī)療保險以及其他類型的醫(yī)療保險,對我國城鄉(xiāng)居民醫(yī)療服務(wù)需求和使用的影響,具體衡量指標(biāo)包括個體是否治療,治療行為選擇決策、醫(yī)療費用總支出決策和個人自付醫(yī)療費用支出決策的影響。 本文的研究結(jié)果表明個體的健康狀況、人口和社會經(jīng)濟特征等異質(zhì)性因素對醫(yī)療服務(wù)需求都有顯著影響。在控制了這些異質(zhì)性因素以后,不同的醫(yī)療保險對個體醫(yī)療服務(wù)需求和使用的差異影響十分顯著。具體分為以下三個方面： 首先,利用Logit模型和Multi-Nominal Logit模型對個體治療行為選擇決策的估計結(jié)果來看,無論居民是否報告患病情況下,相比新型農(nóng)村合作醫(yī)療,其他醫(yī)療保險都會提高個體治療行為發(fā)生概率,尤其是商業(yè)醫(yī)療保險會顯著提高治療行為概率的44%；城鎮(zhèn)職工醫(yī)療保險則會顯著提高12%。其次,利用Heckman樣本選擇模型(two-part)對個體醫(yī)療費用總支出決策模型的估計結(jié)果看,在醫(yī)療支出發(fā)生概率方面,相比新型農(nóng)村合作醫(yī)療,商業(yè)醫(yī)療保險會顯著提高個體醫(yī)療支出發(fā)生概率的33%,城鎮(zhèn)職工醫(yī)療保險則會顯著提高9%。在醫(yī)療費用總支出大小方面,相比新型農(nóng)村合作醫(yī)療,城鎮(zhèn)居民醫(yī)療保險覆蓋人群的個人醫(yī)療費用總支出會顯著增加59%,即1844元(按平均醫(yī)療支出3111元計算)；而享有公費醫(yī)療的人群的醫(yī)療總支出會顯著增加125%,即3895元(按平均醫(yī)療支出3111元計算)。同時,根據(jù)收入彈性的計算公式和計量回歸結(jié)果得出全部樣本的醫(yī)療支出的收入彈性為0.127。再次,利用兩部分模型對個人自付醫(yī)療費用支出決策模型的估計結(jié)果看,第一,在個人自付醫(yī)療支出發(fā)生概率方面,相對新型農(nóng)村合作醫(yī)療而言,商業(yè)醫(yī)療保險會降低個人自付醫(yī)療支出發(fā)生概率的2%。第二,在發(fā)生個人自付醫(yī)療費用支出情況下,相比新型農(nóng)村合作醫(yī)療,商業(yè)醫(yī)療保險會顯著降低個人自付醫(yī)療支出的26%,約533元(按照個人自付醫(yī)療費用支出平均2022元計算)；而城鎮(zhèn)居民醫(yī)療保險覆蓋人群的個人自付醫(yī)療支出會顯著增加56%,約1131元(按照個人自付醫(yī)療費用支出平均2022元計算)。而城鎮(zhèn)職工醫(yī)療保險和公費醫(yī)療并沒有發(fā)現(xiàn)顯著影響。第三,在個人自付醫(yī)療費用負(fù)擔(dān)比例方面,不同醫(yī)療保險的影響也存在顯著差異。相比新型農(nóng)村合作醫(yī)療,享有公費醫(yī)療人群和城鎮(zhèn)職工醫(yī)療保險覆蓋人群的個人自付醫(yī)療負(fù)擔(dān)比例都顯著降低8%，，商業(yè)醫(yī)療保險和城鎮(zhèn)居民醫(yī)療保險人群的個人自付醫(yī)療費用負(fù)擔(dān)比例會更高,但都并不顯著。 因此,本文得出以下主要結(jié)論：在控制了個體健康狀況、社會經(jīng)濟等特征的異質(zhì)性因素后,不同保障水平和籌資水平的醫(yī)療保險對城鄉(xiāng)居民的醫(yī)療服務(wù)需求的差異影響十分顯著。從治療行為選擇決策來看,相比新型農(nóng)村合作醫(yī)療,城鎮(zhèn)職工醫(yī)療保險和商業(yè)醫(yī)療保險在改善和提高個體治療行為方面起到了更為積極的作用。從醫(yī)療需求總支出方面來看,相比新型農(nóng)村合作醫(yī)療,城鎮(zhèn)職工醫(yī)療保險和商業(yè)醫(yī)療保險提高了醫(yī)療需求總支出發(fā)生概率,而城鎮(zhèn)居民醫(yī)療保險和公費醫(yī)療卻提高了個體醫(yī)療需求總支出大小。從個人自付醫(yī)療費用支出來看,相比新型農(nóng)村合作醫(yī)療,商業(yè)醫(yī)療保險降低了個人自付醫(yī)療支出發(fā)生概率,同時也會顯著降低個人自付醫(yī)療費用總支出；而城鎮(zhèn)居民醫(yī)療保險的個人自付醫(yī)療費用支出顯著更高；城鎮(zhèn)職工醫(yī)療保險和公費醫(yī)療去顯著降低個人自付醫(yī)療支出負(fù)擔(dān)比例。 這一研究結(jié)果表明,包括商業(yè)醫(yī)療保險在內(nèi)的五種醫(yī)療保險中,公費醫(yī)療處于最好的地位,城鎮(zhèn)職工居于次好地位,商業(yè)醫(yī)療保險則僅次于城職保,城鎮(zhèn)居民醫(yī)療保險和新型農(nóng)村合作醫(yī)療則處于相對較差的地位。首先,享有公費醫(yī)療的人群醫(yī)療費用支出最高且個人自付醫(yī)療負(fù)擔(dān)最低；其次為城鎮(zhèn)職工醫(yī)療保險,顯著提高個體的治療行為發(fā)生,并在提高醫(yī)療服務(wù)需求的同時,降低個人自付醫(yī)療負(fù)擔(dān)；再次是商業(yè)醫(yī)療保險,也提高了個體的治療行為,同時降低個人自付醫(yī)療支出發(fā)生和自付醫(yī)療總支出；而新型農(nóng)村合作醫(yī)療和城鎮(zhèn)居民醫(yī)療保險覆蓋人群則處于相對較差的地位,治療行為發(fā)生概率較低且醫(yī)療需求總支出也較低,但個人自付醫(yī)療負(fù)擔(dān)較重。而城鎮(zhèn)居民醫(yī)療保險的個人醫(yī)療需求總支出和個人自負(fù)醫(yī)療支出都顯著高于新型農(nóng)村合作醫(yī)療,但是個人醫(yī)療負(fù)擔(dān)比例也相對較高。 可見由于醫(yī)療保險制度本身設(shè)計差異,導(dǎo)致了原本基于城鄉(xiāng)收入和健康不平等基礎(chǔ)之上的個體醫(yī)療服務(wù)需求和使用的不平等,進一步加劇;而醫(yī)療服務(wù)需求和使用的不平等,會進一步拉大城鄉(xiāng)居民健康的不平等和收入的不平等,最終會影響到整個社會經(jīng)濟發(fā)展和穩(wěn)定。因此,應(yīng)采取有效措施,縮小不同醫(yī)療保險制度之間保障水平的差異,并降低個人自付醫(yī)療費用負(fù)擔(dān),真正實現(xiàn)全體國民享有的公平的、平等的、有效的基本衛(wèi)生服務(wù),最終提高全體國民的健康水平。
[Abstract]:In order to establish the "basic medical security for all" system, and to ensure that everyone is able to obtain the basic medical and health services without dividing the region, nationality, age, sex, occupation and income level, the medical and health system of "basic medical and health services for all" is realized, and the medical and health system in our country is constantly reformed and perfected. With the expansion of the coverage of basic medical insurance in China, the national medical insurance system covering urban and rural areas has been basically formed. At present, the basic medical security system in China is based on new rural cooperative medical care, basic medical insurance for urban residents, basic medical insurance of urban workers and urban and rural medical assistance as the main body, covering rural population and Urban Non - urban medical insurance, respectively. The employment population, the urban employment population and the urban and rural people have solved the unfair problem of the lack of medical insurance for some people. However, on the other hand, the design of the system itself has gradually exposed many problems with the further deepening of the implementation. The two yuan structure of urban and rural areas makes the residents at a healthy level and the accessibility of medical services. There is a large gap in sex, while different medical insurance systems provide economic risk protection, there are great differences in medical insurance payment standard, treatment level, scope of insurance and reimbursement ratio. It is possible to further widen the use of medical services and the gap between urban and rural residents, and may lead to the health level of urban and rural residents. At the same time, the new rural cooperative medical insurance system of the basic medical insurance system, the three main body system of urban occupational insurance and city residence insurance: the new rural cooperative medical system, the basic medical insurance of urban residents and the basic medical insurance of urban workers and towns, and the different management institutions and management system have caused the low efficiency of the system operation.
Based on the above research background, this paper makes a comprehensive application of microeconomics, insurance economics, health economics, econometrics and other methods, which is based on the theory of medical service demand and the basic theory of medical insurance. On the one hand, from a macro perspective, it describes the implementation effect of different medical insurance systems in both international and domestic. From the micro perspective, this paper empirically examines the differences in the impact of different types of basic medical insurance on the medical service demand and use of urban and rural residents in China, including commercial medical insurance.
Based on the basic theories of microeconomics, insurance economics and health economics, this paper expounds the theory of health and medical service demand theory and medical insurance demand theory as well as the influence theory of medical insurance on medical service demand, and then reviews and summarizes the choice of medical insurance to treatment behavior from foreign and domestic research documents. The focus of this study is to estimate the different types of medical insurance by using the new rural cooperative medical service as the reference group, using the cross-sectional data of "China's health and pension tracking survey (CHARLS)" in 2008, using different measurement methods, using the cross section data of "China's health and pension tracking survey (CHARLS)" in 2008. It includes basic medical insurance for urban workers, basic medical insurance of urban residents, public medical and commercial medical insurance and other types of medical insurance, which affect the needs and use of medical service in urban and rural areas of our country. The specific measure includes the treatment of individual, the decision of choice of treatment behavior, the decision of the total expenditure of medical expenses and the total expenditure. The impact of personal payment on medical expenses.
The results of this study show that the individual health status, population and socioeconomic characteristics have significant influence on the medical service demand. After controlling these heterogeneity factors, different medical insurance has ten significant differences on the individual medical service demand and use, which are divided into the following three aspects:
First of all, using the Logit model and the Multi-Nominal Logit model to estimate the decision of individual treatment behavior selection, it is found that no matter whether the residents report the illness or not, compared with the new rural cooperative medical care, the other medical insurance will increase the probability of individual treatment behavior, especially the commercial medical insurance will significantly increase the probability of treatment behavior. 44%, the medical insurance of urban workers will be significantly improved by 12%.. Using the Heckman sample selection model (two-part) to estimate the decision model of the total expenditure of individual medical expenses, compared with the new rural cooperative medical service, the commercial medical insurance will significantly increase the probability of the occurrence of individual medical expenditure by 33%, The medical insurance of urban workers will significantly increase the total expenditure of 9%. in the total expenditure of medical expenses. Compared with the new rural cooperative medical service, the total expenditure of individual medical expenses of urban residents' medical insurance coverage will increase by 59%, that is 1844 yuan (according to the average medical expenditure of 3111 yuan). A significant increase of 125%, that is 3895 yuan (according to the average medical expenditure of 3111 yuan). At the same time, according to the calculation formula of the income elasticity and the regression results, the income elasticity of the medical expenditure of all the samples is 0.127. again. Using the two part model to estimate the individual self paid medical expense decision model, first, the personal self pay medicine. Compared with the new rural cooperative medical system, the commercial medical insurance will reduce the 2%. second of the probability of personal medical expenditure. Compared with the new type of rural cooperative medical care, the commercial medical insurance will significantly reduce the personal medical expenditure by 26%, about 533 yuan (according to the new rural cooperative medical service). According to an average of 2022 yuan for individual self paid medical expenses, the individual self payment of medical insurance coverage for urban residents would significantly increase by 56%, about 1131 yuan (according to an average of 2022 yuan per person's self paid medical expense). The medical insurance and public health care of urban workers did not have significant impact. Third There are significant differences in the impact of medical insurance on the proportion of medical expenses. Compared with the new type of rural cooperative medical care, the proportion of individual self paid medical burden to the public medical workers and the medical insurance coverage of urban workers has been significantly reduced by 8%. The personal self payment of the medical insurance and the medical insurance of urban residents The proportion of the cost of treatment will be higher, but it is not significant.
Therefore, this paper draws the following main conclusions: after controlling the heterogeneity of individual health status and social and economic characteristics, medical insurance with different level of security and level of financing has a significant impact on the difference of medical service demand between urban and rural residents. Workers' medical insurance and commercial medical insurance have played a more active role in improving and improving individual treatment behavior. From the total expenditure of medical demand, compared with the new rural cooperative medical system, urban workers' medical insurance and commercial medical insurance have improved the probability of the total expenditure of medical demand, and the medical insurance of urban residents and the medical insurance of urban residents. Compared with the new type of rural cooperative medical care, the commercial medical insurance reduces the probability of individual self paid medical expenditure, and also significantly reduces the total expenditure of individual self paid medical expenses. The cost of medical treatment is significantly higher; medical insurance and public health care for urban employees will significantly reduce the proportion of personal expenses for medical expenses.
The results show that, of the five kinds of medical insurance, including commercial medical insurance, public health care is in the best position, the urban workers are in the best position, the commercial medical insurance is second only to the urban occupational insurance, the urban residents' medical insurance and the new rural cooperative medical care are in a relatively poor position. The group medical expenditure is the highest and the personal medical burden is the lowest, the second is the medical insurance of urban workers, which significantly improves the individual's treatment behavior, and reduces the personal medical burden while improving the medical service demand. Again, it is the commercial medical insurance, which also improves the individual's treatment behavior and reduces the individual self paid medical treatment. The new rural cooperative medical care and the medical insurance coverage of urban residents are in a relatively poor position, the probability of the treatment behavior is low and the total expenditure of medical demand is low, but the personal medical burden is heavy. Personal expense is significantly higher than that of the new rural cooperative medical system, but the proportion of personal medical burden is relatively high.
It can be seen that the differences in the design of the medical insurance system have resulted in the unequal demand for and use of individual medical services based on urban and rural income and unequal health, and the inequality in the demand for medical services and the unequal use of medical services will further increase the inequality of health and income inequality between urban and rural residents, and ultimately, Therefore, effective measures should be taken to reduce the difference in the level of security between different medical insurance systems, reduce the burden of personal medical expense, and truly realize the fair, equal and effective basic health service enjoyed by all the citizens, and ultimately improve the health of all the people.
【學(xué)位授予單位】：南開大學(xué)
【學(xué)位級別】：博士
【學(xué)位授予年份】：2013
【分類號】：R197.1;F842.684

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相關(guān)博士學(xué)位論文 前3條

1 黎成;新醫(yī)改背景下我國全民醫(yī)療保險體系改革研究[D];第四軍醫(yī)大學(xué);2011年

2 黃楓;中國城鎮(zhèn)健康需求和醫(yī)療保險改革研究[D];西南財經(jīng)大學(xué);2010年

3 董黎明;我國城鄉(xiāng)基本醫(yī)療保險一體化研究[D];東北財經(jīng)大學(xué);2011年

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