本文選題：新農(nóng)合 + 結(jié)防機構(gòu)門診費用　； 參考：《山東大學》2012年碩士論文

【摘要】：結(jié)核病是由結(jié)核桿菌引起的慢性傳染性疾病,其中以肺結(jié)核最為常見,據(jù)世界衛(wèi)生組織報道,全球已有近1/3的人口感染過結(jié)核桿菌,每年新發(fā)結(jié)核病患者870萬例,每年死于結(jié)核病的患者大約200萬例。我國是全球22個結(jié)核病高負擔國家之一,結(jié)核病患者數(shù)之多居世界第二；目前我國5億人感染結(jié)核桿菌,600多萬人患肺結(jié)核,其中200萬患者具有傳染性,每年死于此病的患者數(shù)達25萬人之多,是各類傳染病總死亡人數(shù)的2倍以上 我國第四次全國結(jié)核病流行病學抽樣調(diào)查結(jié)果顯示80%的結(jié)核病患者在農(nóng)村,3/4的患者為具有生產(chǎn)能力的青壯年。2004年開始我國推行了針對結(jié)核病患者的免費政策,但是免費政策只包括五種一線抗結(jié)核藥物和部分檢查項目(包括四次痰涂片和一次胸片檢查),共計約250元�；颊咴趯嶋H治療的過程中還需要接受肝功能等其他方面的檢查和輔助治療,治療費用遠遠高于減免費用,絕大多數(shù)患者難以負擔結(jié)核病的治療費用,經(jīng)濟障礙直接影響了貧困家庭肺結(jié)核患者的就醫(yī)。 新型農(nóng)村合作醫(yī)療制度(以下簡稱新農(nóng)合)是我國農(nóng)村居民的基本醫(yī)療保障制度,2003年試點以來運行情況良好。很多學者已經(jīng)達成了利用醫(yī)療保障減輕結(jié)核病患者疾病經(jīng)濟負擔的共識,各地也展開了這方面的嘗試。目前關(guān)于結(jié)防門診納入新農(nóng)合補償方面的研究大多關(guān)注納入后新農(nóng)合對結(jié)核病防治管理工作的作用,而以何種方式納入,納入后的補償政策以及納入后在政策實施過程中的監(jiān)管等問題研究較少。 研究目的 本研究分析目前項目縣地區(qū)新農(nóng)合資金運行情況以及新農(nóng)合對結(jié)核病的補償政策；分析在當前新農(nóng)合補償政策下,結(jié)核病供需雙方的行為及患者的費用負擔情況；研究結(jié)防門診費用納入新農(nóng)合補償、提高結(jié)防機構(gòu)門診費用的報銷比例對新農(nóng)合資金的影響；設(shè)計合理的結(jié)核病患者補償服務(wù)包,明確結(jié)核病補償?shù)乃幤贰z查種類,報銷比例,補償方式等。 研究方法 本研究根據(jù)目的性抽樣原則、結(jié)防機構(gòu)門診費用是否在新農(nóng)合報銷范圍內(nèi)、目前新農(nóng)合對結(jié)核病的報銷方式,選取浙江省和四川省為項目省。根據(jù)成組設(shè)計兩樣本均數(shù)比較的樣本量估計公式、當?shù)亟Y(jié)核病流行情況、患者代表性等因素決定每省選取4個項目縣,每縣調(diào)查患者50名�；颊哌x取原則為2009年1月1日起至2009年12月31日為止在縣結(jié)防機構(gòu)登記且至現(xiàn)場調(diào)查前治愈或完成療程的新發(fā)肺結(jié)核患者,患者應(yīng)全部為加入新農(nóng)合,年齡小于65歲的當?shù)鼐用?非重癥、未合并嚴重并發(fā)癥或合并癥且非耐藥患者(嚴重并發(fā)癥包括II型、嚴重肝、腎功能不全、嚴重心肺疾病、精神疾病、腫瘤等)。最終選取浙江省長興縣、安吉縣、桐廬縣、新昌縣,四川省簡陽市、雁江區(qū)、仁壽縣、東坡區(qū)為項目縣,共調(diào)查392名患者,同時收集這些患者在結(jié)防機構(gòu)治療的病案。本研究還訪談了項目縣衛(wèi)生局新農(nóng)合辦公室主任、結(jié)防機構(gòu)負責人、結(jié)防機構(gòu)醫(yī)生,共24人。此外本研究還利用新農(nóng)合機構(gòu)調(diào)查表和結(jié)防機構(gòu)調(diào)查表收集了項目縣新農(nóng)合基金收入支出數(shù)據(jù)、社會經(jīng)濟基本情況、結(jié)核病流行情況及結(jié)防機構(gòu)基本情況,同時收集了項目縣2005-2009年5年的新農(nóng)合政策文件。 本研究通過描述性分析、x2檢驗、秩和檢驗、多因素分析等方法分析研究項目縣患者的醫(yī)療費用、疾病負擔、供需雙方行為、結(jié)防門診費用的影響因素等。 研究結(jié)果 1.項目縣新農(nóng)合補償政策 浙江省各項目縣目前新農(nóng)合補償模式均為門診統(tǒng)籌+住院統(tǒng)籌,門診費用均按比例報銷,住院費用均分段按比例報銷,報銷比例隨醫(yī)療機構(gòu)級別的變化而變化。四川省各項目縣均實行家庭賬戶+住院統(tǒng)籌的報銷方式,每人每年30元劃入家庭門診賬戶用于門診醫(yī)療費用的報銷,住院費用按比例報銷。各縣根據(jù)當?shù)氐男罗r(nóng)合基金運行情況及財政狀況制定了門診特殊病種、二次補償?shù)冗M一步的補償政策。新農(nóng)合診療目錄顯示結(jié)核病診療常用檢查(X線、血常規(guī)、尿常規(guī)、肝功、腎功等)以及一線抗結(jié)核藥物均在報銷范圍內(nèi),而二線藥、保肝藥、免疫制劑等輔助用藥則不在報銷口錄內(nèi)。 2.項目縣新農(nóng)合基金運行情況 調(diào)查表收集資料顯示各項目縣新農(nóng)合實施以來,籌資標準、基金總額不斷上升；起付線降低,報銷比例和封頂線不斷提高；基金運行平穩(wěn),沒有出現(xiàn)風險。但是仍然存在門診補償支出比例過低,結(jié)余率過高的問題。 3.項目縣新農(nóng)合對結(jié)核病的補償政策 除國家推行的結(jié)核病免費政策外,浙江省安吉縣、桐廬縣,四川省簡陽市、雁江區(qū)還對結(jié)防機構(gòu)門診費用實行了進一步的補償政策,其余各項目縣患者的結(jié)防機構(gòu)門診費用無法得到報銷。安吉、長興、簡陽三地結(jié)核病患者在其他機構(gòu)發(fā)生的門診費用按照特殊病種政策進行補償,其他項目縣患者在其他機構(gòu)發(fā)生的門診費用以及所有項目縣患者在其他機構(gòu)發(fā)生的住院費用與其他疾病的報銷政策相同。 4.患者結(jié)核病治療費用及疾病經(jīng)濟負擔 浙江省納入組患者醫(yī)療費用為4660元,占家庭總收入比例為43%,災難性支出比例為28%；浙江省未納入組患者醫(yī)療費用為5895元,占家庭總收入比例為29%,災難性支出比例為44%；四川省納入組患者醫(yī)療費用為4161元,占家庭總收入比例為55%,災難性支出比例為49%；四川省未納入組患者醫(yī)療費用為3879元,占家庭總收入比例為70%,災難性支出比例為41%； 醫(yī)療費用的報銷在一定程度上可以降低患者的疾病經(jīng)濟負擔,總費用報銷比例在10%左右,報銷后總醫(yī)療費用占年家庭收入的比例比報銷前降低10%左右,報銷后災難性支出比報銷前降低5%左右。 5.患者的就診過程分析 研究發(fā)現(xiàn)絕大多數(shù)患者都是通過其他機構(gòu)轉(zhuǎn)診至結(jié)防機構(gòu)的,僅有10%左右的患者是直接到結(jié)防機構(gòu)就診的�；颊咧饕煽h級和鄉(xiāng)級醫(yī)療機構(gòu)轉(zhuǎn)診至結(jié)防機構(gòu),沒有人因為結(jié)防機構(gòu)報銷比例高而就診,所有項目縣患者平均就診機構(gòu)數(shù)均超過2個,長興縣就診機構(gòu)數(shù)甚至超過了3個。 6.提高新農(nóng)合對結(jié)防機構(gòu)門診費用補償比例對新農(nóng)合基金的影響 根據(jù)收集到的各省項目縣的新發(fā)患者登記數(shù)、患者人均費用、新農(nóng)合門診補償支出計算新農(nóng)合結(jié)核病補償支出占新農(nóng)合門診補償支出的比例進行推算。通過分析發(fā)現(xiàn)隨著新農(nóng)合門診補償支出的不斷增加,結(jié)核病補償支出占新農(nóng)合門診補償支出的比例不斷降低。即使將結(jié)防門診費用的報銷比例提高到100%,用于結(jié)核病的補償支出才不到五十萬,占新農(nóng)合門診支出比例遠遠小于1%,可見提高結(jié)防機構(gòu)門診費用的報銷比例對新農(nóng)合基金影響較小。 訪談對象對提高新農(nóng)合對結(jié)核病報銷比例意見各異,結(jié)防機構(gòu)負責人和結(jié)防醫(yī)生因直接與患者接觸,了解患者的負擔,都認為應(yīng)該提高新農(nóng)合對結(jié)防門診費用的報銷比例,他們也指出這需要相關(guān)部門的配合及政府的支持。新農(nóng)合機構(gòu)負責人表示不支持提高新農(nóng)合對結(jié)核病的報銷比例,因新農(nóng)合基金有限,應(yīng)向癌癥、器官移植等大病傾斜。 政策建議 1.加強肺結(jié)核相關(guān)知識的宣傳力度,提高農(nóng)村居民對肺結(jié)核癥狀、定點治療單位、免費治療政策的了解； 2.提高社會各界對肺結(jié)核病的重視程度,使大家認識到結(jié)核病是一項社會問題,關(guān)系到人民的生活、健康和社會發(fā)展,需要重視； 3.需要將結(jié)防門診費用納入新農(nóng)合報銷范圍,以降低患者負擔并提高肺結(jié)核病患者歸口治療管理率和依從性； 4.可以通過按比例報銷的方式對肺結(jié)核患者進行補償,需要擴充新農(nóng)合藥品報銷目錄,改善報銷程序,方便群眾報銷；也可以通過將結(jié)核病作為特殊病種等其他方式對結(jié)核病患者進行補償； 5.可以通過定額補助的方式對肺結(jié)核患者進行補償,同時需要提高補助額度并取消起付線； 6.在改善新農(nóng)合對肺結(jié)核患者補償政策的同時需要加強監(jiān)管,防治供方誘導需求和需方道德?lián)p害的發(fā)生。
[Abstract]:Tuberculosis is a chronic infectious disease caused by TB , among which tuberculosis is the most common , according to the World Health Organization . More than 1 / 3 of the world ' s population has been infected with TB , with 8.7 million new TB patients per year , with some 2 million people dying from tuberculosis each year . My country is one of the 22 high - burden countries in the world , with the largest number of tuberculosis patients in the world .
At present , 500 million people are infected with tuberculosis , more than 6 million people suffer from tuberculosis , of which 2 million have infectious diseases , and the number of patients dying each year is more than 250,000 people , and is more than twice the total number of total deaths of all kinds of infectious diseases

The fourth national tuberculosis epidemic survey in China shows that 80 % of tuberculosis patients in rural areas and 3 / 4 are in rural areas with productive capacity . Since 2004 , China has introduced free policy for tuberculosis patients , but the free policy only includes five first - line anti - tuberculosis drugs and partial inspection items ( including four sputum smear and one chest examination ) , which is far higher than the relief cost . Most of the patients have difficulty in the treatment of tuberculosis , and economic barriers directly affect the treatment of tuberculosis patients in poor families .

The new rural cooperative medical system ( hereinafter referred to as " Xingnong " ) is the basic medical security system of rural residents in our country , and the operation is good since the pilot project in 2003 . Many scholars have reached consensus on the use of medical security to reduce the economic burden of tuberculosis patients .

Purpose of study

This paper analyzes the operation of Xingnong combined funds in the current project and the compensation policy of Xingnong combined with tuberculosis ;
To analyze the behavior of tuberculosis supply and demand and the burden of patient ' s expenses under the current new agricultural co - compensation policy ;
To study the effect of the proportion of reimbursement of outpatient expenses on the new non - farm funds .
Design rational tuberculosis patient compensation service package , clear tuberculosis compensation medicine , check kind , reimbursement proportion , compensation mode and so on .

Research Methods

According to the principle of objective sampling , whether the cost of outpatient outpatient services is within the reimbursement scope of the new farming , the current new non - agricultural co - operation has selected 4 project counties in Zhejiang and Sichuan Province , and 50 patients in each county are selected according to the sample size estimation formula , the local tuberculosis epidemic situation and the representative of the patient . The patients should be all the local residents who have been cured or completed the treatment course before the site investigation . The patients should be enrolled in Xinong , and the patients with non - resistant patients ( serious complications including type II , severe liver , renal insufficiency , severe cardiopulmonary disease , mental illness , tumor , etc . ) . A total of 392 patients were selected from Changxing County , Anji County , Tonglu County , Xinchang County , Sichuan Jianyang City , Yanjiang District , Renshou County and Dongpo District .

Through descriptive analysis , x2 test , rank sum test and multi - factor analysis , this study analyzed the medical expenses , disease burden , supply and demand behavior of patients in the project county , and the influencing factors of outpatient costs .

Results of the study

1 . New Rural Cooperative Compensation Policy in Project County

In each county of Zhejiang Province , the current new farming and compensation mode is outpatient co - integration + hospitalization , and the outpatient expenses are reimbursed according to the proportion , and the reimbursement rate varies according to the change of the medical institution level . All counties in Sichuan Province have adopted a family account + hospitalization and integrated reimbursement method . Each county has established outpatient special disease type and secondary compensation according to the state of operation and financial situation of the local New Rural Cooperative Fund . The new agriculture combined diagnosis and treatment catalog shows that tuberculosis diagnosis and treatment common examination ( X - ray , blood routine , urine routine , liver function , kidney work , etc . ) and first - line anti - tuberculosis drugs are within the reimbursement range , while supplementary drugs such as second - line medicine , liver - protecting medicine and immune preparation are not in the reimbursement document .

2 . Operation of Xingnong Cooperation Fund in Project County

The data collected from the questionnaire shows that since the implementation of the new agriculture and agriculture in each project county , the fund - raising standards and the total fund have risen continuously ;
The decrease of the pay - down line , the proportion of reimbursement and the continuous improvement of the capping line ;
The fund runs smoothly and there is no risk . However , there is still a problem of low proportion of outpatient compensation expenditure and over - balance rate .

3 . Compensation policy for tuberculosis in project counties

In addition to the country ' s free policy of tuberculosis free of charge , further compensation policy has been applied to the outpatient costs of tuberculosis prevention institutions in Anji County , Tonglu County , Jianyang City and Yanjiang District of Zhejiang Province . The outpatient costs of patients in other projects are not reimbursable . The outpatient costs incurred by other institutions in Anji , Changxing and Jianyang are reimbursed according to the special case policies , and the outpatient costs incurred by patients in other projects in other institutions as well as the hospitalization expenses incurred by patients in other projects in other institutions are the same as those of other diseases .

4 . Cost of tuberculosis treatment for patients and economic burden of diseases

The medical cost of the patients in Zhejiang Province was 4660 yuan , accounting for 43 % of total household income and 28 % for disastrous expenditure ;
The medical cost of the non - enrolled patients in Zhejiang Province was 5895 yuan , accounting for 29 % of total household income and 44 % for disastrous expenditure ;
The medical cost of the patients in Sichuan province was 4161 yuan , accounting for 55 % of total household income and 49 % for disastrous expenditure ;
The medical expenses of the patients who were not included in the group were 3879 yuan , accounting for 70 % of total household income and 41 % for disastrous expenditure ;


Reimbursement of medical expenses can reduce the patient ' s disease economic burden to a certain extent , the proportion of total cost reimbursement is about 10 % , the proportion of total medical expenses after reimbursement is about 10 % lower than that before reimbursement , and the disastrous expenditure after reimbursement is about 5 % less than that before reimbursement .

5 . Analysis of patient ' s medical procedure

The study found that the majority of patients were transferred to the junction prevention facility through other institutions . Only about 10 % of the patients were directly to the junction defense mechanism . The patient was mainly transferred from county and township medical institutions to the junction prevention institution , and no one visited the junction because of the high reimbursement rate of the anti - defense mechanism . The average number of patients in all project counties was more than 2 , and the number of medical institutions in Changxing County was even more than 3 .

6 . To improve the effect of the proportion of the compensation ratio of the outpatient expenses of the new agricultural association on the New Rural Cooperative Fund

According to the number of new patient registration , the per capita cost of the patient and the compensation expenditure of Xingnong combined outpatient service , the proportion of the compensation expenditure of Xingnong combined outpatient service is calculated according to the number of new patients registered in each province project county . The proportion of the compensation expenditure for tuberculosis is less than 500,000 , which accounts for less than 1 % of the expenditure of the new agriculture combined outpatient service , even if the proportion of reimbursement of the outpatient expenses of the new agriculture combined outpatient service is increased to 100 % .

The participants also pointed out that the proportion of reimbursement of new non - outpatient expenses should be improved , and the proportion of reimbursement of new non - agricultural co - operation against tuberculosis should be improved . The head of the new agriculture association said it would not support the increase of the proportion of reimbursement for tuberculosis , and the new farm association fund should be inclined to cancer , organ transplantation and other major diseases .

policy recommendations

1 . Strengthen the propaganda of tuberculosis - related knowledge , improve the awareness of rural residents about the symptoms of pulmonary tuberculosis , fixed - point treatment units and free treatment policies ;


2 . To increase the level of attention paid to tuberculosis by all sectors of society and to recognize tuberculosis as a social problem , bearing in mind the people ' s lives , health and social development , requiring attention ;


3 . It is necessary to include the cost of junction anti - outpatient services in the reimbursement range of the new farmers , so as to reduce the burden of the patients and improve the management rate and compliance of the return treatment of patients with pulmonary tuberculosis ;


4 . The patients with pulmonary tuberculosis can be compensated according to the proportion of reimbursement , so as to expand the reimbursement directory of new agricultural chemicals , improve the reimbursement procedure and facilitate the reimbursement of the masses ;
tuberculosis patients can also be compensated by using tuberculosis as a special disease or the like ;


5 . The patients with pulmonary tuberculosis can be compensated in the form of fixed allowance , and the allowance limit should be increased and the pay - off line shall be cancelled ;


6 . In order to improve the compensation policy of the patients with pulmonary tuberculosis , it is necessary to strengthen the supervision and control the demand of the supplier and the occurrence of the moral damage of the demander .
【學位授予單位】：山東大學
【學位級別】：碩士
【學位授予年份】：2012
【分類號】：R521;R197.1

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