基于疾病经济风险的农村贫困人口医疗保障制度研究
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摘要
研究目的
通过现场调查获取农村贫困和非贫困人口在参加医疗保障制度后的卫生服务需求和利用、疾病费用支付和补偿等信息,利用疾病经济风险衡量指标,比较评价现行农村医疗保障制度抵御贫困和非贫困人口疾病经济风险的效果并对其影响因素进行分析,依此提出农村贫困人口医疗保障制度的改进策略,以提高医疗保障制度对农村贫困人口疾病经济风险的抵御能力。
研究方法
1、文献研究方法
系统回顾分析风险管理、健康贫困及医疗保障等方面的相关理论及实证研究,着重关注并归纳其中有关疾病经济风险评价、应对及干预的技术方法和制度设计等。
2、专家咨询
本研究就评价维度及指标的筛选进行专家咨询,采取两轮的专家咨询,通过遴选专家对初步评价框架进行开放式评议来调整和确定疾病经济风险评价维度及指标。
3、现场调查
采取多阶段分层随机抽样方法,根据地域分布和社会经济状况,分别选取浙江省(温岭市、建德市、文成县)、湖北省(京山县、公安县、咸丰县)、重庆市(九龙坡区、涪陵区、黔江区)等三省(市)的九个县域作为样本县,每个县随机抽取贫困户和非贫困户居民各100户进行入户调查。贫困户采取由当地村医或村干部主观认定的方式选取。现场调查实际共完成1697户的家庭询问调查,其中重庆市592户、湖北省673户、浙江省432户。回收有效问卷1661份,其中贫困户815份,非贫困户846份,共包含农村居民6502人,其中贫困人口3240人,非贫困人口3262人。
4、数据分析方法
数理计算：通过公式计算评价指标中的发生率、发生深度及集中指数等：描述性分析：计量资料的均值、标准差计算；计数资料和率、频数分布描述；单因素分析：计量资料的t检验、One-Way ANOVA、Mann-Whitney U检验、Kruskal-Wallis H检验；计数资料的卡方检验。所有数理计算采用Microsoft Office Excel2007软件进行；数据分析采用SPSS for Windows12.01专业统计软件处理。
研究结果
1、通过文献回顾分析和专家咨询,归纳确定了农村居民疾病经济风险评价的维度和指标。最终确立的疾病经济风险评价框架主要包括绝对经济风险和相对经济风险两个维度,其中绝对经济风险是基于风险的自然属性,分别从风险概率和风险损失额两个方面进行评价；相对经济风险则基于风险的社会属性,分别从相对风险度、灾难性卫生支出和致贫性卫生支出等三个方面进行评价。
2、利用确立的疾病经济风险评价的维度和指标,对农村贫困和非贫困人口的疾病经济风险现状进行了比较分析,结果表明：(1)从对农村居民绝对疾病经济风险的评估来看,在风险概率方面,贫困人口的慢性病患病概率和因慢性病住院的概率均显著高于非贫困人口,但是在卫生服务利用上,贫困人口的两周患病未治疗率显著高于非贫困人口,且贫困人口的就诊层次相对更低,贫困人口的卫生服务利用行为更易受到经济因素的制约。而在风险损失额方面,贫困人口的两周自我治疗费用显著低于非贫困人口,但在门诊就医借贷的发生概率和借贷额度上均显著高于非贫困人口。(2)从对农村居民相对疾病经济风险的评估来看,在相对风险度方面,贫困人口年医疗费用总支出引起的疾病经济风险是是非贫困人口的3.25倍；在灾难性卫生支出方面,贫困家庭年卫生总支出引起的灾难性卫生支出发生概率是非贫困家庭的1.81倍,发生灾难性卫生支出的贫困家庭的年卫生支出高达其年经济收入的3.37倍；而在致贫性卫生支出方面,贫困人群的致贫性卫生支出发生率是非贫困人群的4.31倍,由此带来的贫困平均缺口是非贫困人群的1.87倍,贫困家庭因病致贫的概率是非贫困家庭的3.22倍,发生过度卫生支出的概率是非贫困家庭的1.88倍。而通过考察不同卫生支出项目引起的疾病经济风险发现,慢性病门诊治疗费用和住院费用是患者及其家庭疾病经济风险的主要来源。
3、对现行农村医疗保障制度抵御贫困和非贫困人口疾病经济风险的效果进行比较分析,结果表明：(1)从绝对疾病经济风险的角度来看,现行农村医疗保障制度对于农村居民疾病风险概率的影响甚微,在贫困和非贫困人口的自我治疗费用补偿及住院补偿方面也均无显著差异。(2)从相对疾病经济风险的角度来看,医疗保障制度补偿前后贫困和非贫困家庭的灾难性卫生支出发生率分别降低了11.67%和19.05%,致贫性卫生支出发生率分别降低了10.60%和26.22%,医疗保障制度补偿在总体上相对有利于非贫困人口；新型农村合作医疗制度的补偿效果也呈现出同样局面,表现出一定的逆向补偿倾向。与此同时,单独的医疗救助补偿及其同新农合的衔接也均未能在缓解农村贫困人口的疾病经济风险中发挥应有的积极作用。
4、结合本研究现场调查数据的特点,对可干预的潜在影响因素进行了分析。结果表明,不同医保制度的住院总体补偿比例间具有显著的统计学差异,新农合的补偿效果显著较低；不同住院流向参合居民的住院补偿比例间具有显著的统计学差异,补偿比例随着住院层次的提升而逐步降低；贫困人口因报销范围外的药品费用而未获补偿的比例显著高于非贫困人口；过度住院医疗费用在总体上对样本人群的疾病经济风险影响不大,但也会加深农村居民尤其是农村贫困人口的贫困深度,
研究结论
1、农村贫困家庭或人群在补偿前的疾病经济风险明显高于非贫困家庭或人群,慢性病门诊治疗费用和住院费用是患者及其家庭疾病经济风险的主要来源。
2、现行农村医疗保障制度在抵御贫困人口疾病经济风险上的总体效果要明显差于非贫困人口,表现出明显的不公平。
3、医疗保障制度的本身设计和运行状况是其抗风险能力及效果的直接影响因素,同时医患双方行为也能够对农村医疗保障制度的抗风险效果产生间接影响。
4、从优化内部制度设计和改善外部运行环境等两方面提出我国农村医疗保障制度的改进策略。其中内部制度设计优化策略主要包括重点提升农村主体医疗保障制度的保障能力、处理好同其他医疗保障制度间的公平关系及鼓励和支持农村商业医疗保险的发展；而外部运行环境改善策略主要包括加快农村基层医疗服务体系建设和加强对医患双方的行为干预。
研究特色与创新
1、本研究在对前期相关评价研究进行系统回顾和归纳总结的基础上,确定了评价疾病经济风险的多重维度和指标,从多维度、多角度系统全面地评价疾病经济风险。
2、本研究探讨了多重保障制度对农村贫困人口疾病经济风险的实际效果和影响因素,从而改进现行医疗保障制度,促进制度间有效衔接。
3、本研究通过对供需双方行为的考察,从医疗保障制度与医疗服务模式的有效整合来思考改进医疗保障制度的策略。
研究局限与不足
1、对于贫困的认定和对家庭范围的界定可能会带来数据统计上的偏倚。
2、数据来源可能会受到回忆性偏倚的干扰,基于横截面数据对医疗保障制度抗风险效果进行的评价可能存在偏差。
3、调查问卷在慢性病调查设计上的缺陷使研究对象的慢性病患病及治疗信息在统计口径上与既往研究相比有所缩小。
4、过度医疗行为的界定方式可能会在较大程度上低估医患双方尤其是医方诱导引起的过度医疗行为。
5、对于农村医疗保障制度抵御疾病经济风险效果的影响因素分析还较为粗放,并未在各个具体的影响因素同医疗保障制度的抗风险能力间建立起定量的相关关系。
6、对于疾病经济风险的分析范围仅限于直接经济负担部分,对于医疗保障制度之外的其他风险应对方式也未深入分析。
Objectives:
Collected the information in health service demand and utilization, medical cost and compensation of the rural poor and non-poor after they participating in medical security system through a site investigation. Adopted the measure indicators of disease economic risk, comparatively evaluated the effect of current rural medical security system in resisting the disease economic risk of the rural poor and non-poor and its influencing factors were analyzed. Based on this, the study proposed the improvement strategies of the rural poor medical security system to improve the ability of medical security system in resisting disease economic risk of the rural poor.
Methods:
1. Literature research methods
Systematically reviewed and analyzed the related theory and empirical researches on risk management, health poverty and medical security. Emphatically concerned summarized the related technological method and system design on the assessment, coping and intervention of disease economic risk.
2. Delphi method
Delphi method had been used in screening the assessment dimensions and indicators. This study had adjusted and determined the assessment dimensions and indicators of disease economic risk through selecting experts to openly appraise and discuss on the preliminary assessment framework.
3. Site investigation
To take multiple stages randomly stratified cluster sampling method, according to regional distribution and social economic situations, Zhejiang Province (Wenling City, Jiande City and Wencheng County), Hubei Province (Jingshan County, Gongan County and Xianfeng County) and Chongqing City (Jiulongpo District, Fuling District and Qianjiang District) were chosen as the sample county.100impoverished rural families (IRFs) and100Non-IRFs were sampled and investigated in each county and the IRFs were confirmed by the subjective recognition of local village doctors or cadres.1697rural families were investigated in the actual site investigation, of which592families in Chongqing,673families in Hubei and432families in Zhejiang. The investigation finally received1661valid questionnaires, which consisted of815IRFs and846Non-IRFs. A grand sum of6502rural residents was included, which consisted of3240poor and3262non-poor.
4. Statistical analysis methods
Mathematical calculation:calculate incidence, intensity and concentration index through the formula; Descriptive analysis; Descriptive Statistics:Mean and S.D. for variable data; frequency and description for attribute data; Univariate Analysis:T-test, One-Way ANOVA, Mann-Whitney U-test and Kruskal-Wallis H-test for variable data; Chi-square for attribute data. All mathematical calculation was processed by Microsoft Office Excel2007and statistical analysis was processed by SPSS for Windows12.01.
Results:
1. This study had summarized and determined the assessment dimensions and indicators of disease economic risk of rural residents. The finally determined assessment framework of disease economic risk mainly included two dimensions:absolute economic risk and relative economic risk, of which absolute economic risk was based on the natural attribute of risk and assessed separately from probability and intensity, relative economic risk was based on the social nature of risk and assessed respectively from the relative risk, catastrophic health care costs and impoverishing health care costs.
2. Adopting the determined assessment dimensions and indicators of disease economic risk, this study had conducted comparatively assessment on the status of disease economic risk of the rural poor and non-poor. The results showed that:(1) from assessment on the absolute economic risk of rural residents, in risk probability, the chronic diseases morbidity and probability of hospitalizing because of chronic diseases of the poor were significantly higher than the non-poor. But in health services utilization, the probability of non-treat in sick of the poor was significantly higher than the non-poor, and level of outpatient service institutions of the poor was relatively lower. Further analysis had concluded that health services utilization behavior of the poor was more vulnerable to economic restriction. And in risk intensity, fortnight self-treatment cost of the poor was significantly lower than the non-poor while the probability and limit of lending because of outpatient service utilization of the poor was significantly higher than the non-poor.(2) from assessment on the relative economic risk of rural residents, in relative risk, the disease economic risk of the poor caused by total medical expenses in the last year was3.25times of the non-poor; In the catastrophic health care costs, the incidence of catastrophic health care costs of the IRFs caused by total health expenses in the last year was1.81times of the Non-IRFs. The total health expenses in the last year of the IRFs that had been exposed to catastrophic health care costs was3.37times of their economic income; And in impoverishing health care costs, the incidence of impoverishing health care costs of the poor was4.31times of the non-poor and the average poverty gap was1.87times of the non-poor, the incidence of impoverished by disease and excessive health expenses in the IRFs was3.22times and1.88times of the Non-IRFs respectively. And what found from the analysis on disease economic risk caused by different sources of health expenses, was that the outpatient treatment cost of chronic diseases and inpatient treatment cost were main sources of disease economic risk of the patients and their families.
3. This study had comparatively analyzed the effect of current rural medical security system in resisting the disease economic risk of the rural poor and non-poor. The results showed that:(1) from the perspective of absolute disease economic risk, the current rural medical security system had a negligible impact on the disease risk probability of rural residents. There were not significant differences in the compensation for self-treatment and inpatient service expenses between the poor and non-poor.(2) from the perspective of relative disease economic risk, the incidence of catastrophic health care costs of the IRFs and Non-IRFs was respectively reduced by11.67%and19.05%after the compensation of medical security system, and the incidence of impoverishing health care costs was respectively reduced by10.60%and26.22%. So the compensation of medical security system was in favor of the non-poor in general. And the new rural cooperative medical system (NCMS) appeared a same situation on its compensation effect and showed reverse compensation tendency in some degree. At the same time, the sole compensation of medical assistance system (MA) and joint compensation of MA and NCMS all had not played a due positive role in resisting disease economic risk of the rural poor.
4. This study had analyzed the potential influence factors that could be intervened based on the features of site investigation data. The results showed that:There were significant differences on the overall compensation proportion for inpatient service expenses among different medical insurance systems. The compensation effect of NCMS was significantly worse. There were significant differences on the compensation proportion for inpatient service expenses among different flows of patients who had joined NCRS, the compensation proportion gradually reduce with the level of inpatient ascending. The proportion of expenses not being compensated because of some drugs not being included in the insurance list in the poor was significantly higher than the non-poor. Although the excessive inpatient expenses had not great influence on the disease economic risk of the sample, it would still strengthen the poverty intensity of rural residents especially the poor.
Conclusions:
1. The disease economic risk of the IRFs was obviously greater than that of the Non-IRFs before getting compensation. The outpatient expenses on chronic diseases and inpatient expenses were the main source of disease economic risk.
2. The general effect of current rural medical security system in resisting disease economic risk of the poor was obviously worse than that of the non-poor what reflected obvious unfair.
3. The design and operation of medical security system were direct influence factors of the ability and effect in resisting disease economic risk. At the same time, the behavior of the patients and doctors also could indirectly infuence the effect of medical security system in resisting disease economic risk.
4. This study proposed improvement strategies of the rural medical security system from optimizing internal system design and improving external operating environment. The strategies in optimizing internal system design included that emphatically enhancing support ability of the main rural medical security system, well dealing with the fairness between the main rural medical security system and others and encouraging and supporting development of the rural commercial medical insurance. While the strategies in improving external operating environment included that accelerating the construction of rural basic medical service system and strengthening intervention of the patients'and doctors' behavior.
Innovations:
1. This study had established multiple evaluation dimensions and indicators of disease economic risk based on roundly reviewing and summarizing related preliminary evaluation researches to systematically evaluate the disease economic risk from multiple dimensions and angles.
2. This study had discussed the actual effects and influencing factors of multiple security system in resisting the disease economic risk of the rural poor, so as to improve the current medical security system and promote the effective connection between them.
3. By researching the behavior of both the supplier and demander, this study thought about the improvement strategies of medical security system from the effective integration between medical security system and medical service mode.
Limitations:
1. The recognition of IRFs and the definition of the scope of family may bring some biases in information statistics.
2. The data source could be affected by memory biases and there possibly were some biases in the evaluation of the effects of medical security system in resisting disease economic risk based on the cross-sectional data.
3. There were some flaws in chronic diseases survey in the questionnaire that made the statistical caliber of information about chronic diseases treatment narrowed compared with previous studies.
4. The definition of excessive medical behavior could greatly undervalued the excessive medical behavior caused by doctors and patients especially doctors inducing.
5. The analysis on influence factors of the effects of rural medical security system in resisting disease economic risk in this study was still extensive relatively and had not established the quantitative relationship between the various specific influence factors and the ability of medical security system in resisting disease economic risk.
6. The scope of analysis on disease economic risk in this study was only limited to the part of direct economic burden and some other risk coping ways except medical security system were also not been analyzed in this study.
通过现场调查获取农村贫困和非贫困人口在参加医疗保障制度后的卫生服务需求和利用、疾病费用支付和补偿等信息,利用疾病经济风险衡量指标,比较评价现行农村医疗保障制度抵御贫困和非贫困人口疾病经济风险的效果并对其影响因素进行分析,依此提出农村贫困人口医疗保障制度的改进策略,以提高医疗保障制度对农村贫困人口疾病经济风险的抵御能力。
研究方法
1、文献研究方法
系统回顾分析风险管理、健康贫困及医疗保障等方面的相关理论及实证研究,着重关注并归纳其中有关疾病经济风险评价、应对及干预的技术方法和制度设计等。
2、专家咨询
本研究就评价维度及指标的筛选进行专家咨询,采取两轮的专家咨询,通过遴选专家对初步评价框架进行开放式评议来调整和确定疾病经济风险评价维度及指标。
3、现场调查
采取多阶段分层随机抽样方法,根据地域分布和社会经济状况,分别选取浙江省(温岭市、建德市、文成县)、湖北省(京山县、公安县、咸丰县)、重庆市(九龙坡区、涪陵区、黔江区)等三省(市)的九个县域作为样本县,每个县随机抽取贫困户和非贫困户居民各100户进行入户调查。贫困户采取由当地村医或村干部主观认定的方式选取。现场调查实际共完成1697户的家庭询问调查,其中重庆市592户、湖北省673户、浙江省432户。回收有效问卷1661份,其中贫困户815份,非贫困户846份,共包含农村居民6502人,其中贫困人口3240人,非贫困人口3262人。
4、数据分析方法
数理计算：通过公式计算评价指标中的发生率、发生深度及集中指数等：描述性分析：计量资料的均值、标准差计算；计数资料和率、频数分布描述；单因素分析：计量资料的t检验、One-Way ANOVA、Mann-Whitney U检验、Kruskal-Wallis H检验；计数资料的卡方检验。所有数理计算采用Microsoft Office Excel2007软件进行；数据分析采用SPSS for Windows12.01专业统计软件处理。
研究结果
1、通过文献回顾分析和专家咨询,归纳确定了农村居民疾病经济风险评价的维度和指标。最终确立的疾病经济风险评价框架主要包括绝对经济风险和相对经济风险两个维度,其中绝对经济风险是基于风险的自然属性,分别从风险概率和风险损失额两个方面进行评价；相对经济风险则基于风险的社会属性,分别从相对风险度、灾难性卫生支出和致贫性卫生支出等三个方面进行评价。
2、利用确立的疾病经济风险评价的维度和指标,对农村贫困和非贫困人口的疾病经济风险现状进行了比较分析,结果表明：(1)从对农村居民绝对疾病经济风险的评估来看,在风险概率方面,贫困人口的慢性病患病概率和因慢性病住院的概率均显著高于非贫困人口,但是在卫生服务利用上,贫困人口的两周患病未治疗率显著高于非贫困人口,且贫困人口的就诊层次相对更低,贫困人口的卫生服务利用行为更易受到经济因素的制约。而在风险损失额方面,贫困人口的两周自我治疗费用显著低于非贫困人口,但在门诊就医借贷的发生概率和借贷额度上均显著高于非贫困人口。(2)从对农村居民相对疾病经济风险的评估来看,在相对风险度方面,贫困人口年医疗费用总支出引起的疾病经济风险是是非贫困人口的3.25倍；在灾难性卫生支出方面,贫困家庭年卫生总支出引起的灾难性卫生支出发生概率是非贫困家庭的1.81倍,发生灾难性卫生支出的贫困家庭的年卫生支出高达其年经济收入的3.37倍；而在致贫性卫生支出方面,贫困人群的致贫性卫生支出发生率是非贫困人群的4.31倍,由此带来的贫困平均缺口是非贫困人群的1.87倍,贫困家庭因病致贫的概率是非贫困家庭的3.22倍,发生过度卫生支出的概率是非贫困家庭的1.88倍。而通过考察不同卫生支出项目引起的疾病经济风险发现,慢性病门诊治疗费用和住院费用是患者及其家庭疾病经济风险的主要来源。
3、对现行农村医疗保障制度抵御贫困和非贫困人口疾病经济风险的效果进行比较分析,结果表明：(1)从绝对疾病经济风险的角度来看,现行农村医疗保障制度对于农村居民疾病风险概率的影响甚微,在贫困和非贫困人口的自我治疗费用补偿及住院补偿方面也均无显著差异。(2)从相对疾病经济风险的角度来看,医疗保障制度补偿前后贫困和非贫困家庭的灾难性卫生支出发生率分别降低了11.67%和19.05%,致贫性卫生支出发生率分别降低了10.60%和26.22%,医疗保障制度补偿在总体上相对有利于非贫困人口；新型农村合作医疗制度的补偿效果也呈现出同样局面,表现出一定的逆向补偿倾向。与此同时,单独的医疗救助补偿及其同新农合的衔接也均未能在缓解农村贫困人口的疾病经济风险中发挥应有的积极作用。
4、结合本研究现场调查数据的特点,对可干预的潜在影响因素进行了分析。结果表明,不同医保制度的住院总体补偿比例间具有显著的统计学差异,新农合的补偿效果显著较低；不同住院流向参合居民的住院补偿比例间具有显著的统计学差异,补偿比例随着住院层次的提升而逐步降低；贫困人口因报销范围外的药品费用而未获补偿的比例显著高于非贫困人口；过度住院医疗费用在总体上对样本人群的疾病经济风险影响不大,但也会加深农村居民尤其是农村贫困人口的贫困深度,
研究结论
1、农村贫困家庭或人群在补偿前的疾病经济风险明显高于非贫困家庭或人群,慢性病门诊治疗费用和住院费用是患者及其家庭疾病经济风险的主要来源。
2、现行农村医疗保障制度在抵御贫困人口疾病经济风险上的总体效果要明显差于非贫困人口,表现出明显的不公平。
3、医疗保障制度的本身设计和运行状况是其抗风险能力及效果的直接影响因素,同时医患双方行为也能够对农村医疗保障制度的抗风险效果产生间接影响。
4、从优化内部制度设计和改善外部运行环境等两方面提出我国农村医疗保障制度的改进策略。其中内部制度设计优化策略主要包括重点提升农村主体医疗保障制度的保障能力、处理好同其他医疗保障制度间的公平关系及鼓励和支持农村商业医疗保险的发展；而外部运行环境改善策略主要包括加快农村基层医疗服务体系建设和加强对医患双方的行为干预。
研究特色与创新
1、本研究在对前期相关评价研究进行系统回顾和归纳总结的基础上,确定了评价疾病经济风险的多重维度和指标,从多维度、多角度系统全面地评价疾病经济风险。
2、本研究探讨了多重保障制度对农村贫困人口疾病经济风险的实际效果和影响因素,从而改进现行医疗保障制度,促进制度间有效衔接。
3、本研究通过对供需双方行为的考察,从医疗保障制度与医疗服务模式的有效整合来思考改进医疗保障制度的策略。
研究局限与不足
1、对于贫困的认定和对家庭范围的界定可能会带来数据统计上的偏倚。
2、数据来源可能会受到回忆性偏倚的干扰,基于横截面数据对医疗保障制度抗风险效果进行的评价可能存在偏差。
3、调查问卷在慢性病调查设计上的缺陷使研究对象的慢性病患病及治疗信息在统计口径上与既往研究相比有所缩小。
4、过度医疗行为的界定方式可能会在较大程度上低估医患双方尤其是医方诱导引起的过度医疗行为。
5、对于农村医疗保障制度抵御疾病经济风险效果的影响因素分析还较为粗放,并未在各个具体的影响因素同医疗保障制度的抗风险能力间建立起定量的相关关系。
6、对于疾病经济风险的分析范围仅限于直接经济负担部分,对于医疗保障制度之外的其他风险应对方式也未深入分析。
Objectives:
Collected the information in health service demand and utilization, medical cost and compensation of the rural poor and non-poor after they participating in medical security system through a site investigation. Adopted the measure indicators of disease economic risk, comparatively evaluated the effect of current rural medical security system in resisting the disease economic risk of the rural poor and non-poor and its influencing factors were analyzed. Based on this, the study proposed the improvement strategies of the rural poor medical security system to improve the ability of medical security system in resisting disease economic risk of the rural poor.
Methods:
1. Literature research methods
Systematically reviewed and analyzed the related theory and empirical researches on risk management, health poverty and medical security. Emphatically concerned summarized the related technological method and system design on the assessment, coping and intervention of disease economic risk.
2. Delphi method
Delphi method had been used in screening the assessment dimensions and indicators. This study had adjusted and determined the assessment dimensions and indicators of disease economic risk through selecting experts to openly appraise and discuss on the preliminary assessment framework.
3. Site investigation
To take multiple stages randomly stratified cluster sampling method, according to regional distribution and social economic situations, Zhejiang Province (Wenling City, Jiande City and Wencheng County), Hubei Province (Jingshan County, Gongan County and Xianfeng County) and Chongqing City (Jiulongpo District, Fuling District and Qianjiang District) were chosen as the sample county.100impoverished rural families (IRFs) and100Non-IRFs were sampled and investigated in each county and the IRFs were confirmed by the subjective recognition of local village doctors or cadres.1697rural families were investigated in the actual site investigation, of which592families in Chongqing,673families in Hubei and432families in Zhejiang. The investigation finally received1661valid questionnaires, which consisted of815IRFs and846Non-IRFs. A grand sum of6502rural residents was included, which consisted of3240poor and3262non-poor.
4. Statistical analysis methods
Mathematical calculation:calculate incidence, intensity and concentration index through the formula; Descriptive analysis; Descriptive Statistics:Mean and S.D. for variable data; frequency and description for attribute data; Univariate Analysis:T-test, One-Way ANOVA, Mann-Whitney U-test and Kruskal-Wallis H-test for variable data; Chi-square for attribute data. All mathematical calculation was processed by Microsoft Office Excel2007and statistical analysis was processed by SPSS for Windows12.01.
Results:
1. This study had summarized and determined the assessment dimensions and indicators of disease economic risk of rural residents. The finally determined assessment framework of disease economic risk mainly included two dimensions:absolute economic risk and relative economic risk, of which absolute economic risk was based on the natural attribute of risk and assessed separately from probability and intensity, relative economic risk was based on the social nature of risk and assessed respectively from the relative risk, catastrophic health care costs and impoverishing health care costs.
2. Adopting the determined assessment dimensions and indicators of disease economic risk, this study had conducted comparatively assessment on the status of disease economic risk of the rural poor and non-poor. The results showed that:(1) from assessment on the absolute economic risk of rural residents, in risk probability, the chronic diseases morbidity and probability of hospitalizing because of chronic diseases of the poor were significantly higher than the non-poor. But in health services utilization, the probability of non-treat in sick of the poor was significantly higher than the non-poor, and level of outpatient service institutions of the poor was relatively lower. Further analysis had concluded that health services utilization behavior of the poor was more vulnerable to economic restriction. And in risk intensity, fortnight self-treatment cost of the poor was significantly lower than the non-poor while the probability and limit of lending because of outpatient service utilization of the poor was significantly higher than the non-poor.(2) from assessment on the relative economic risk of rural residents, in relative risk, the disease economic risk of the poor caused by total medical expenses in the last year was3.25times of the non-poor; In the catastrophic health care costs, the incidence of catastrophic health care costs of the IRFs caused by total health expenses in the last year was1.81times of the Non-IRFs. The total health expenses in the last year of the IRFs that had been exposed to catastrophic health care costs was3.37times of their economic income; And in impoverishing health care costs, the incidence of impoverishing health care costs of the poor was4.31times of the non-poor and the average poverty gap was1.87times of the non-poor, the incidence of impoverished by disease and excessive health expenses in the IRFs was3.22times and1.88times of the Non-IRFs respectively. And what found from the analysis on disease economic risk caused by different sources of health expenses, was that the outpatient treatment cost of chronic diseases and inpatient treatment cost were main sources of disease economic risk of the patients and their families.
3. This study had comparatively analyzed the effect of current rural medical security system in resisting the disease economic risk of the rural poor and non-poor. The results showed that:(1) from the perspective of absolute disease economic risk, the current rural medical security system had a negligible impact on the disease risk probability of rural residents. There were not significant differences in the compensation for self-treatment and inpatient service expenses between the poor and non-poor.(2) from the perspective of relative disease economic risk, the incidence of catastrophic health care costs of the IRFs and Non-IRFs was respectively reduced by11.67%and19.05%after the compensation of medical security system, and the incidence of impoverishing health care costs was respectively reduced by10.60%and26.22%. So the compensation of medical security system was in favor of the non-poor in general. And the new rural cooperative medical system (NCMS) appeared a same situation on its compensation effect and showed reverse compensation tendency in some degree. At the same time, the sole compensation of medical assistance system (MA) and joint compensation of MA and NCMS all had not played a due positive role in resisting disease economic risk of the rural poor.
4. This study had analyzed the potential influence factors that could be intervened based on the features of site investigation data. The results showed that:There were significant differences on the overall compensation proportion for inpatient service expenses among different medical insurance systems. The compensation effect of NCMS was significantly worse. There were significant differences on the compensation proportion for inpatient service expenses among different flows of patients who had joined NCRS, the compensation proportion gradually reduce with the level of inpatient ascending. The proportion of expenses not being compensated because of some drugs not being included in the insurance list in the poor was significantly higher than the non-poor. Although the excessive inpatient expenses had not great influence on the disease economic risk of the sample, it would still strengthen the poverty intensity of rural residents especially the poor.
Conclusions:
1. The disease economic risk of the IRFs was obviously greater than that of the Non-IRFs before getting compensation. The outpatient expenses on chronic diseases and inpatient expenses were the main source of disease economic risk.
2. The general effect of current rural medical security system in resisting disease economic risk of the poor was obviously worse than that of the non-poor what reflected obvious unfair.
3. The design and operation of medical security system were direct influence factors of the ability and effect in resisting disease economic risk. At the same time, the behavior of the patients and doctors also could indirectly infuence the effect of medical security system in resisting disease economic risk.
4. This study proposed improvement strategies of the rural medical security system from optimizing internal system design and improving external operating environment. The strategies in optimizing internal system design included that emphatically enhancing support ability of the main rural medical security system, well dealing with the fairness between the main rural medical security system and others and encouraging and supporting development of the rural commercial medical insurance. While the strategies in improving external operating environment included that accelerating the construction of rural basic medical service system and strengthening intervention of the patients'and doctors' behavior.
Innovations:
1. This study had established multiple evaluation dimensions and indicators of disease economic risk based on roundly reviewing and summarizing related preliminary evaluation researches to systematically evaluate the disease economic risk from multiple dimensions and angles.
2. This study had discussed the actual effects and influencing factors of multiple security system in resisting the disease economic risk of the rural poor, so as to improve the current medical security system and promote the effective connection between them.
3. By researching the behavior of both the supplier and demander, this study thought about the improvement strategies of medical security system from the effective integration between medical security system and medical service mode.
Limitations:
1. The recognition of IRFs and the definition of the scope of family may bring some biases in information statistics.
2. The data source could be affected by memory biases and there possibly were some biases in the evaluation of the effects of medical security system in resisting disease economic risk based on the cross-sectional data.
3. There were some flaws in chronic diseases survey in the questionnaire that made the statistical caliber of information about chronic diseases treatment narrowed compared with previous studies.
4. The definition of excessive medical behavior could greatly undervalued the excessive medical behavior caused by doctors and patients especially doctors inducing.
5. The analysis on influence factors of the effects of rural medical security system in resisting disease economic risk in this study was still extensive relatively and had not established the quantitative relationship between the various specific influence factors and the ability of medical security system in resisting disease economic risk.
6. The scope of analysis on disease economic risk in this study was only limited to the part of direct economic burden and some other risk coping ways except medical security system were also not been analyzed in this study.
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