农村居民慢性非传染性疾病经济风险及其影响因素和风险管理策略研究
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摘要
研究背景
随着社会经济的发展,生活方式和饮食结构变化、环境恶化以及人口老龄化进程加快等原因使得我国的疾病谱发生了巨大变化,慢性非传染性疾病已成为威胁我国农村居民健康的重要卫生问题。2008年,全国有医生明确诊断的慢病病例数达到2.6亿,平均每年新增慢病病例1000万例,其中,高血压病和糖尿病的病例数增加了2倍,心脏病和恶性肿瘤的病例数增加了近1倍。由于患病率高、并发症多、易复发、治疗周期长和预后差等特点,慢病带来沉重疾病负担的同时,也给我国居民造成了沉重的经济负担,据世界卫生组织估计,到2015年,我国慢病直接医疗费用将超过5000亿美元。尤其是对于农村家庭来说,慢病医疗费用支出增长远高于农民收入的增长,这进一步放大了疾病风险对农村居民的经济冲击,农村居民及其家庭面临着严峻的慢病经济风险。新农合制度作为我国农村地区的主要医疗保障制度,是疾病经济风险管理策略中重要的正式机制,其核心作用就是抵御疾病带来的经济风险。
疾病经济风险的产生是一个连续而动态的过程,产生过程中各环节的危险因素都会对风险的水平造成决定性的影响,对疾病经济风险及其管理的研究应该结合风险产生的整个路径进行,而目前有关疾病经济风险管理的研究大多是围绕医疗保障制度的风险保护作用进行的,另外有些研究是从疾病导致的医疗费用发生后患者或家庭如何利用自身以及外部资源应对的角度分析。目前还没有研究结合疾病经济风险产生的整个过程、针对农村居民及其家庭因慢病导致的经济风险的水平、分布和影响因素进行全面系统地分析,也没有研究借助社会风险管理的概念框架这一科学的风险管理模式从风险发生前的预防、缓和与发生后的应对三个方面对农村居民慢病经济风险的管理策略进行实证分析。
在当前我国农村地区慢病患病率不断升高、治疗费用迅速增长、农村居民应对疾病经济风险的能力不足、“因病致贫、因病返贫”现象严重的形势下,明确农村居民慢病经济风险的产生路径、对农村居民因慢病导致的经济风险的水平进行测量并分析风险的影响因素、考察农村居民的慢病风险管理策略,尤其是正式策略——新农合制度减轻其慢病经济风险的作用具有重要意义。
研究目的
本研究的总体目标是通过系统回顾和总结疾病经济风险的国内外研究成果,结合现场调查资料,对农村居民的慢病经济风险进行系统研究,以理清慢病经济风险的产生路径,明确农村居民及其家庭因慢病导致的经济风险的水平及其影响因素,提出降低农村居民慢病经济风险的政策建议。具体目的包括：构建慢病经济风险产生路径和风险管理的理论框架；分析慢病经济风险产生路径各环节(慢病患病、治疗及费用)的影响因素；从慢病病例及其家庭两个层面分别测量慢病经济风险的水平,分析慢病经济风险的影响因素；考察农村居民的慢病经济风险管理策略,尤其是新农合补偿对降低风险的作用；针对疾病经济风险产生路径的各个环节提出慢病经济风险管理的政策建议。
资料来源与研究方法
本研究的资料主要来源于文献资料和现场调查。通过文献复习,介绍疾病经济风险的概念,总结其常用的测量指标,归纳其影响因素及分析方法,并在社会风险管理概念框架的基础上,提出了慢病经济风险的产生路径和风险管理的理论框架。本研究的现场调查采用分层随机抽样的方法,根据社会经济发展水平,随机抽取济南市3个县,每个样本县按经济状况和新农合覆盖率的不同随机抽取3个乡镇,共9个乡镇,每个乡镇按同样的方法随机抽取6个村,共54个村。根据每个村的户主花名册进行等距抽样,每村抽取20户农村居民,共调查984户、3458名农村居民,作为本研究的对象。调查家庭的一般情况、家庭成员的基本情况、调查前一年慢病卫生服务需求及利用的情况；资料分析方法主要包括描述性分析、单因素分析和多因素分析(包括二部模型法、非条件二分类Logistic回归等),统计分析软件为SPSS15.0。
主要研究结果
1.慢病患病、治疗、费用的情况及其影响因素
以患病人数和患病例数计算的慢病患病率分别为19.38%和23.34%,循环系统疾病是最主要的疾病构成(47.21%),其中又以高血压患病率为最高；年龄高、过量饮酒是慢病患病概率的危险因素,高受教育程度、高收入是保护因素。
调查前一年慢病病例的治疗率为88.23%,自我医疗率为48.17%,未治疗率为11.77%,应住院而未住院率为1.73%,经济困难是慢病病例未治疗和未住院的重要原因；慢病病例的年治疗费用平均为1534.79元,其中住院(648.75元)和门诊治疗费用(624.44元)占82.96%,药店购药治疗的费用最少,为261.60元。
慢病病例治疗概率和治疗费用的二部模型分析结果表明,自感健康状况和系统疾病种类是影响慢病治疗概率和治疗费用的显著因素。自感健康状况一般及较差的人群治疗率和治疗费用均高于自感健康状况较好者,循环系统疾病、消化系统疾病、内分泌系统疾病和其他系统疾病的患者慢病治疗概率和治疗费用均高于肌肉骨骼系统和结缔组织疾病患者；此外,卫生服务的可及性(最近医疗机构的距离是否在200米以内)对慢病治疗概率有显著影响,而对治疗费用没有显著影响。
2.慢病经济风险的水平及其影响因素
(1)慢病病例和慢病家庭的经济风险水平
慢病人群的相对疾病经济风险为总样本人群的2.50倍(校正RR=2.50),其中低收入组的相对经济风险最高(校正RR=5.71),过去一年治疗了慢病的病例中有50.28%的病例因慢病治疗费用而发生了高经济风险；慢病家庭中因慢病治疗费用所致灾难性卫生支出发生率为20.68%,平均差距和相对差距分别为10.28%和49.73%,灾难性卫生支出发生的集中指数为-0.314,说明灾难性卫生支出较多发生在低收入家庭中。
(2)慢病病例和慢病家庭经济风险的影响因素
收入、自感健康状况、是否住院治疗以及系统疾病种类是影响慢病病例高经济风险发生率的显著因素。随着收入水平的提高,慢病病例的高经济风险发生概率逐渐降低；自感健康状况一般及较差者比较好者的高风险发生概率高(OR=2.256);过去一年住院治疗慢病的病例比没有住院的高风险发生概率高；患有不同种类系统疾病的病例高风险发生概率之间也存在显著差异,肌肉骨骼系统和结缔组织疾病的病例高风险发生概率最低。
慢病家庭灾难性卫生支出发生概率的显著影响因素包括家庭总人口数、家中慢病患者人数、家中是否有慢病患者住院、家庭收入、所在县区、户主职业。灾难性卫生支出发生率随着家庭总人口数的增加和收入水平的提高而降低,随家中慢病患病人数的增加而增加；过去一年家中有慢病患者住院的家庭比没有住院的家庭灾难性卫生支出的发生概率高(OR=10.936)；不同县区的灾难性卫生支出的发生率也存在差异,章丘的最低；户主职业为农民的家庭灾难性卫生支出的发生率高于户主职业非农民的家庭。
3.慢病病例及其家庭的风险管理策略分析
(1)风险预防策略：慢病人群吸烟率(18.98%)、过量饮酒率(16.98%)略高于总样本人群的平均水平(18.28%、14.40%)；慢病家庭环境卫生状况次于样本家庭,自来水普及率(76.88%)、清洁能源普及率(47.43%)均低于样本家庭平均水平(78.35%、52.95%)；调查前一年样本人群中仅有29.06%(1005人)的调查对象接受过新农合的免费体检,慢病人群的体检率为33.21%,尚不足三分之一。
(2)风险缓和策略：慢病家庭的收入来源多样化指数(0.570)略低于总样本家庭(0.585)；慢病家庭的物质资本和人力资本储备能力低于总样本家庭,有存款的慢病家庭比例(34.21%)低于总样本家庭(36.59%),慢病家庭的平均人口数略高于总样本家庭,而其劳动年龄人口数和自感健康状况较好者的人数均低于总样本家庭；过去一年慢病病例的治疗率为88.23%,自我医疗率为48.17%,未治疗率为11.77%；有慢病患者的家庭参合率为99.06%,略高于总样本家庭(98.48%)。
72.62%的慢病病例得到了新农合的补偿,新农合对慢病治疗费用的实际补偿比为10.42%；新农合补偿使4.77%的慢病病例摆脱了高风险状态,高经济风险发生率下降程度为9.49%；新农合补偿使3.20%的慢病家庭摆脱了灾难性卫生支出,灾难性卫生支出发生率的下降程度为15.47%,平均差距、相对差距分别下降了1.44和6.95个百分点,下降程度为13.97%。
(3)风险应对策略：利用自己家庭的现金或存款(非正式机制)是慢病病例及其家庭应对慢病治疗费用的主要策略(96.78%),其他正式和非正式应对策略的利用比例均不到5%。患者家庭自付费用是慢病治疗费用的最主要来源,占全部治疗费用的77.13%,其次,11.29%的慢病治疗费用来自于社会网络(主要是亲戚朋友)的馈赠和借款；而正式应对机制(医疗救助补贴和银行贷款)分担的比例不足3%。
结论与政策建议
本研究对样本地区农村居民慢病经济风险产生路径的各个环节(慢病患病、治疗及费用的情况)及其影响因素、慢病病例和家庭的疾病经济风险水平及影响因素以及慢病经济风险的管理策略进行了分析,发现：样本地区农村居民慢病患病率、治疗率高(但自我医疗率高)、慢病治疗费用及其给慢病患者和家庭造成的经济风险高；年龄高、过量饮酒是慢病患病的危险因素,高受教育程度和高收入是保护因素；自感健康状况和系统疾病的种类是影响慢病治疗概率和治疗费用的显著因素,卫生服务可及性也是慢病治疗率的影响因素,经济困难是造成居民未就诊和未住院的重要原因；高收入是慢病病例经济风险高低的保护因素,住院治疗是危险因素,自感健康状况和系统疾病的种类也是影响慢病病例经济风险高低的显著因素；而家庭收入、家庭总人口数、家中慢病患者人数、家中是否有慢病患者住院、户主职业是影响慢病家庭灾难性卫生支出发生概率的显著因素。样本地区慢病病例及其家庭的慢病经济风险管理策略中,对预防策略重视程度不够；缓和策略作用有限,其中正式风险缓和机制——新农合制度的补偿对减轻慢病病例及其家庭经济风险的能力不足；风险应对策略以非正式机制为主,其中,家庭现金卫生支出是最主要的于段。
基于上述结论,提出慢病经济风险预防、缓和与应对的三级管理模式：风险预防：(1)加强慢病相关知识宣传教育,倡导积极健康的生活方式,最大限度地降低各种慢病的患病率,从根本上预防慢病导致的经济风险；(2)将健康体检等预防保健服务纳入新农合补偿范围,建立健康档案,对慢病患者进行系统管理,防止病情加重、预防并发症的发生。
风险缓和：(1)继续扩大新农合覆盖面,进一步提高新农合筹资水平,改变“先垫付、后报销”的程序；(2)将慢病逐步纳入新农合大病统筹,进一步提高慢病住院补偿标准；(3)引导患者积极合理就医,充分利用基层卫生服务机构,降低慢病治疗花费；(4)鼓励以市场为基础的商业医疗保险在农村地区的发展；(5)鼓励农村居民从事多种收入活动,增加家庭收入以实现缓和、分散慢病经济风险的目的。
风险应对：(1)实现医疗救助制度与新农合制度的协同发展和有效衔接；(2)促进农村地区信贷机构等正式风险应对机制的发展；(3)进一步发挥社会网络等非正式风险应对机制的作用。
Background
As the development of social economy and the improvement of living standard, the changes in life style and diet structure, environmental deterioration, accelerating ageing etc. bring about significant changes in the spectrum of diseases in our country. Non-communicable chronic diseases (NCDs) are becoming the main threat to the health of rural residents. In2008, the number of chronic cases was260million and was increasing by10million new cases each year. Among them, cases with hypertension and diabetes increased by2times. Due to high prevalence, multi-complications, long duration of treatment and bad prognosis, NCDs patients and families need to pay substantial medical expenses, resulting in heavy economic burdens. The World Health Organization estimated that the direct medical expenses will exceed500billion US Dollars. Especially for rural households, NCDs'medical expenditure increases much faster than their income, which further magnifies economic shocks of disease risk towards rural residents, so that their families face tremendous NCDs'financial risk. Against this risk, rural residents and their households have already formed a serious of risk management strategies, one of which is rural cooperative medical care system (NCMS), the principal medical scheme in rural areas. Its core function is to protect farmers from being inflicted by disease financial risk.
The generation and development of the disease financial risk is a successive process, which will be affected by all kinds of risk factors in this process, so that researches on disease financial risk and its management should be based on this whole process. However, most researches on disease financial risk management stand in the perspective of responding after risk happened. So far, there has been no systematic research on the generating path, level, distribution and determinants of rural resident and their households'financial risk due to NCDs, as well as influencing factors on each part of the whole process. Besides, it lacks empirical analysis of NCD's financial risk management strategies from risk prevention, mitigation and coping with the application of Social Risk Management framework.
At the background of continuously increasing NCDs prevalence and medical expenses in rural areas of our country, inadequacy of capacity to respond to disease financial risk, and farmers'being into or back into poverty by illness, it's of great significance to explicit generating path of rural resident's NCDs financial risk, measure financial risk level resulted by NCDs, analyze influencing factors on risk and inspect the risk management strategies of rural residents/households, NCMS's function to reduce disease financial risk in particular.
Objectives
General objective of this study is to systematically research on rural residents'NCDs financial risk, disentangle its generating path, explicit its level and influencing factors among rural residents and their households by means of reviewing, summarizing domestic/abroad research results and analyzing data from field survey, in order to propose policy implications reducing rural residents'financial risk due to NCDs. Specific objectives includes:to build the theoretical framework of NCDs financial risk's generating path and its management; to analyze the influencing factors of each part of this path, to measure the level of rural residents and their households'financial risk due to NCDs, explore the determinants of NCDs financial risk; investigate NCDs financial risk management strategies of rural residents, especially NCMS's function to reduce risk; to make policy suggestions for managing rural residents'NCDs financial risk.
Data and Methods
The data source of this study relied mainly on literature review and field investigation. Through the review of the literature, this analysis introduced the concept of financial risks due to NCDs, summarized its commonly used evaluation indicators and summed up the affecting factors and analytical methods. In addition, the study proposed the theoretical framework of generation path and risk management of the NCDs based on the conceptual frame of social risk management. The study employed a stratified random sampling method, with3counties of Jinan selected. Within each county,18villages spread across3townships were selected to participate in the survey. About20households were randomly selected per village, resulting in a total sample of3458rural residents in984households as respondents. This survey mainly included family general information, basic situation of family members and situation of health service demand and utilization of chronic diseases of the previous year before survey. Data analysis methods were mainly descriptive analysis, univariate analysis and multivariate analysis (including Two-part model, Non-conditional Binary Logistic regression analysis, Multivariate Linear Regression Analysis). The Statistical analysis software used was SPSS15.0for windows.
Results
1. Rural Residents'NCDs Prevalence, Treatment, Costs and their Determinants The prevalence rates calculated on the basis of number of NCDs patients and number of cases was19.38%and23.34%, respectively, both of which were higher than the NCDs prevalence rate from the national health services survey in2008. Rural residents in the sampled areas were facing higher risk of NCDs. Circulatory system diseases were the most important constitute of NCDs among sampled population (47.21%), in which the prevalence rate of hypertension was the highest. Multivariate analysis of NCDs prevalence rate indicated that advanced age and alcohol abusing were risk factors, while higher income, higher education level were protective factors. During the year before survey, the treatment rate of NCDs cases was88.23%, self treatment rate was48.17%, non-treatment rate was11.77%, and the rate of non-hospitalization was1.73%. Financial hardship is the main factor of non-treatment and non-hospitalization for chronic cases. The average annual treatment costs on NCDs was1534.79RMB, among which per capita inpatient and outpatient treatment cost were648.75and624.44RMB, respectively, while the medicine cost in drugstore was the least (261.60RMB).
The two-part model analysis of NCDs treatment rate and cost indicated that perceived health status and the type of system diseases were significant affecting factors. The treatment rate and cost of patients whose perceived health status was poorer were higher than those with better health status. The treatment rate and cost in circulatory system diseases, digestive system diseases, endocrine system disease and other system diseases were higher than musculoskeletal system diseases and connective tissue diseases. In addition, health service accessibility (whether the nearest medical institution was within200meters) had a significant effect on the NCDs treatment rate, while no significant effect on the treatment cost.
2. Rural Residents'Financial Risk due to NCDs and its Determinants
(1) Financial risk of chronic cases and their families
The income of chronic patients and their families was lower than the average level of the sample while health expenditure was higher than the average. The relative financial risk of chronic cases is2.50times of the total sample (adjusted RR=2.50), and the low-income group had the highest relative risk (adjusted RR=5.71). During the past year,50.28%of the chronic cases who had treatment were in the higher financial risk due to costs of treatment;20.68%of the households with chronic patients had experienced catastrophic health payments due to the cost of NCDs treatment, while the mean gap and mean positive gap were10.28%and49.73%, respectively, the concentration index of catastrophic health payments was-0.314, which indicated that catastrophic health payments were more likely to occur in families with lower income.
(2) Determinants of financial risk of chronic patients and their family
Multivariate analysis showed that income, perceived health status, hospitalization and the category of diseases are significant factors influencing NCDs cases'financial risk. The probability of higher financial risk decreased with the increase of income; cases with worse and normal perceived health status have higher probability of financial risk than better health status (Odds Ratio=2.256). Cases who had hospitalization in the past year had higher probability than non-hospitalization cases. The probability is significantly different among different types of system diseases, and cases with musculoskeletal system and connective tissue diseases had lower risk. Significant factors influencing the probability of catastrophic health expenditures in households with chronic patients were the household's total population, the number of chronic patients in the family, whether hospitalized or not, household income, county and the occupation of the household head. Headcount of catastrophic health payments decreased with the increase of the household's total population and income, and increased with the number of chronic patients in households. Those households with patients who had hospitalized in the past year had higher probability of catastrophic health payments. The incidence of catastrophic health expenditures was different among counties and Zhangqiu had the lowest incidence. Those households which the head of household is farmer had higher incidence than non-farmers.
3. Rural Residents'Risk Management Strategies of Financial Risk due to NCDs
(1)Risk Prevention Strategies:smoking rate of NCDs cases (18.98%) and excessive alcohol consumption rate (16.98%) was slightly higher than the average rate of sample population (18.28%,14.40%). Sanitation situation of households with NCDs cases was inferior to that of sample households. Proportion of tap water (76.88%) and clean energy (47.43%) of households with NCDs was lower than sample households. During the year before the survey, only29.06%(1005) of the sampled population and33.21%of NCDs cases received free medical examination from NCMS.
(2)Risk Mitigation Strategies:Income resource diversification index of households with NCDs (0.570) was slightly lower than that of sampled households (0.585).The proportion of chronic disease household with deposit (34.21%) was lower than that of sample households (36.59%). The average household population of households with NCDs was slightly higher than that of sample households, but the number of working age population and the self-inductance of health status was lower than that of sampled households. Treatment of chronic disease cases in the past year was88.23%, self-medication was48.17%, no treatment was11.77%; the rate of chronic disease families joining NCMS was99.06%, slightly higher than that of sample households (98.48%).72.62%of the cases were compensated by NCMS, the actual compensation rate of NCMS was10.42%; NCMS made4.77%of cases of chronic disease get rid of the high-risk status, the degree of incidence of high economic risk level decreased by9.49%;the NCMS compensation let3.20%of chronic disease families flee from catastrophic health expenditure, and the incidence of catastrophic health expenditure dropped by15.47%, the average gap and the relative gap declined by1.44%and6.95%, respectively, a drop of13.97%.
(3)Risk Coping Strategies:Using cash or deposits of their own family (informal mechanisms) was the main strategy of households with NCDs patients to cope with NCDs treatment costs (96.78%of households with NCDs paid for medical expenses by cash or deposit), the use of other formal and informal coping strategies was less than5%. The main source of NCDs treatment costs was Out-of-pocket of the households, accounting for77.13%of total costs. Only3%of the costs were from the formal risk coping mechanism, including medical assistance and commercial insurance.
Conclusions and Policy Implications
Rural residents'NCDs prevalence rates and treatment rates were higher in the sample region. NCDs treatment costs and its financial risks to NCDs cases and families were high; Advanced age, excessive drinking were risk factors of NCDs prevalence; Higher education level and higher income were protective factors; Perceived health status and types of system disease were significant factors which affected NCDs treatment probability and costs; Health service accessibility was also affecting factor of NCDs treatment rates, and economic hardship was an important reason for NCDs cases not to use health services. Income level, whether using hospitalization services, perceived health status and types of system disease were significant factors affecting chronic cases'financial risk; While household income, the household's total population, the number of NCDs patients, whether there were hospitalized patients in the household and the career of householders were significant factors of the probability of households'catastrophic health expenditure. As to rural residents'financial risk management strategies for chronic disease, prevention strategies were not emphasized, mitigation strategies had a limited effect, and the compensation capacity of NCMS, which is the main formal means in coping strategies, is inadequate for sharing the NCDs cases of and their families'financial risk. Based on the above findings, we propose a three-level management model for NCDs financial risk which includes prevention, mitigation and coping strategies:
Risk prevention:(1) to strengthen publicity and education of chronic disease-related knowledge, to promote active and healthy lifestyle to minimize the prevalence of NCDs, to fundamentally prevent financial risks caused by NCDs;(2) to include physical examination in NCMS compensation range, to conduct physical examination for residents and establish health records, and undergo systematic management for chronic patients, to prevent exacerbations and prevent complications.
Risk mitigation:(1) to continue to expand the NCMS coverage, further improve the NCMS funding levels, and change the "first pay, then get reimbursement" process;(2) to gradually incorporate NCDs into NCMS arrangement for serious diseases, to further improve the standard of chronic disease hospital compensation;(3) to guide patients to a reasonable medical treatment, full use of primary health services, reduce chronic disease treatment costs;(4) to promote the development of formal mitigation mechanisms based on market, e.g. commercial insurance;(5) to encourage rural residents to engage in multiple income sources and increase their income to disperse financial risk due to NCDs.
Risk coping:(1) to fulfill the joint development and effective interface of medical assistance system and NCMS;(2) to promote the development of formal coping mechanisms based on market, e.g. credit institutions;(3) to expand the role of informal risk-coping mechanisms of social networks.
随着社会经济的发展,生活方式和饮食结构变化、环境恶化以及人口老龄化进程加快等原因使得我国的疾病谱发生了巨大变化,慢性非传染性疾病已成为威胁我国农村居民健康的重要卫生问题。2008年,全国有医生明确诊断的慢病病例数达到2.6亿,平均每年新增慢病病例1000万例,其中,高血压病和糖尿病的病例数增加了2倍,心脏病和恶性肿瘤的病例数增加了近1倍。由于患病率高、并发症多、易复发、治疗周期长和预后差等特点,慢病带来沉重疾病负担的同时,也给我国居民造成了沉重的经济负担,据世界卫生组织估计,到2015年,我国慢病直接医疗费用将超过5000亿美元。尤其是对于农村家庭来说,慢病医疗费用支出增长远高于农民收入的增长,这进一步放大了疾病风险对农村居民的经济冲击,农村居民及其家庭面临着严峻的慢病经济风险。新农合制度作为我国农村地区的主要医疗保障制度,是疾病经济风险管理策略中重要的正式机制,其核心作用就是抵御疾病带来的经济风险。
疾病经济风险的产生是一个连续而动态的过程,产生过程中各环节的危险因素都会对风险的水平造成决定性的影响,对疾病经济风险及其管理的研究应该结合风险产生的整个路径进行,而目前有关疾病经济风险管理的研究大多是围绕医疗保障制度的风险保护作用进行的,另外有些研究是从疾病导致的医疗费用发生后患者或家庭如何利用自身以及外部资源应对的角度分析。目前还没有研究结合疾病经济风险产生的整个过程、针对农村居民及其家庭因慢病导致的经济风险的水平、分布和影响因素进行全面系统地分析,也没有研究借助社会风险管理的概念框架这一科学的风险管理模式从风险发生前的预防、缓和与发生后的应对三个方面对农村居民慢病经济风险的管理策略进行实证分析。
在当前我国农村地区慢病患病率不断升高、治疗费用迅速增长、农村居民应对疾病经济风险的能力不足、“因病致贫、因病返贫”现象严重的形势下,明确农村居民慢病经济风险的产生路径、对农村居民因慢病导致的经济风险的水平进行测量并分析风险的影响因素、考察农村居民的慢病风险管理策略,尤其是正式策略——新农合制度减轻其慢病经济风险的作用具有重要意义。
研究目的
本研究的总体目标是通过系统回顾和总结疾病经济风险的国内外研究成果,结合现场调查资料,对农村居民的慢病经济风险进行系统研究,以理清慢病经济风险的产生路径,明确农村居民及其家庭因慢病导致的经济风险的水平及其影响因素,提出降低农村居民慢病经济风险的政策建议。具体目的包括：构建慢病经济风险产生路径和风险管理的理论框架；分析慢病经济风险产生路径各环节(慢病患病、治疗及费用)的影响因素；从慢病病例及其家庭两个层面分别测量慢病经济风险的水平,分析慢病经济风险的影响因素；考察农村居民的慢病经济风险管理策略,尤其是新农合补偿对降低风险的作用；针对疾病经济风险产生路径的各个环节提出慢病经济风险管理的政策建议。
资料来源与研究方法
本研究的资料主要来源于文献资料和现场调查。通过文献复习,介绍疾病经济风险的概念,总结其常用的测量指标,归纳其影响因素及分析方法,并在社会风险管理概念框架的基础上,提出了慢病经济风险的产生路径和风险管理的理论框架。本研究的现场调查采用分层随机抽样的方法,根据社会经济发展水平,随机抽取济南市3个县,每个样本县按经济状况和新农合覆盖率的不同随机抽取3个乡镇,共9个乡镇,每个乡镇按同样的方法随机抽取6个村,共54个村。根据每个村的户主花名册进行等距抽样,每村抽取20户农村居民,共调查984户、3458名农村居民,作为本研究的对象。调查家庭的一般情况、家庭成员的基本情况、调查前一年慢病卫生服务需求及利用的情况；资料分析方法主要包括描述性分析、单因素分析和多因素分析(包括二部模型法、非条件二分类Logistic回归等),统计分析软件为SPSS15.0。
主要研究结果
1.慢病患病、治疗、费用的情况及其影响因素
以患病人数和患病例数计算的慢病患病率分别为19.38%和23.34%,循环系统疾病是最主要的疾病构成(47.21%),其中又以高血压患病率为最高；年龄高、过量饮酒是慢病患病概率的危险因素,高受教育程度、高收入是保护因素。
调查前一年慢病病例的治疗率为88.23%,自我医疗率为48.17%,未治疗率为11.77%,应住院而未住院率为1.73%,经济困难是慢病病例未治疗和未住院的重要原因；慢病病例的年治疗费用平均为1534.79元,其中住院(648.75元)和门诊治疗费用(624.44元)占82.96%,药店购药治疗的费用最少,为261.60元。
慢病病例治疗概率和治疗费用的二部模型分析结果表明,自感健康状况和系统疾病种类是影响慢病治疗概率和治疗费用的显著因素。自感健康状况一般及较差的人群治疗率和治疗费用均高于自感健康状况较好者,循环系统疾病、消化系统疾病、内分泌系统疾病和其他系统疾病的患者慢病治疗概率和治疗费用均高于肌肉骨骼系统和结缔组织疾病患者；此外,卫生服务的可及性(最近医疗机构的距离是否在200米以内)对慢病治疗概率有显著影响,而对治疗费用没有显著影响。
2.慢病经济风险的水平及其影响因素
(1)慢病病例和慢病家庭的经济风险水平
慢病人群的相对疾病经济风险为总样本人群的2.50倍(校正RR=2.50),其中低收入组的相对经济风险最高(校正RR=5.71),过去一年治疗了慢病的病例中有50.28%的病例因慢病治疗费用而发生了高经济风险；慢病家庭中因慢病治疗费用所致灾难性卫生支出发生率为20.68%,平均差距和相对差距分别为10.28%和49.73%,灾难性卫生支出发生的集中指数为-0.314,说明灾难性卫生支出较多发生在低收入家庭中。
(2)慢病病例和慢病家庭经济风险的影响因素
收入、自感健康状况、是否住院治疗以及系统疾病种类是影响慢病病例高经济风险发生率的显著因素。随着收入水平的提高,慢病病例的高经济风险发生概率逐渐降低；自感健康状况一般及较差者比较好者的高风险发生概率高(OR=2.256);过去一年住院治疗慢病的病例比没有住院的高风险发生概率高；患有不同种类系统疾病的病例高风险发生概率之间也存在显著差异,肌肉骨骼系统和结缔组织疾病的病例高风险发生概率最低。
慢病家庭灾难性卫生支出发生概率的显著影响因素包括家庭总人口数、家中慢病患者人数、家中是否有慢病患者住院、家庭收入、所在县区、户主职业。灾难性卫生支出发生率随着家庭总人口数的增加和收入水平的提高而降低,随家中慢病患病人数的增加而增加；过去一年家中有慢病患者住院的家庭比没有住院的家庭灾难性卫生支出的发生概率高(OR=10.936)；不同县区的灾难性卫生支出的发生率也存在差异,章丘的最低；户主职业为农民的家庭灾难性卫生支出的发生率高于户主职业非农民的家庭。
3.慢病病例及其家庭的风险管理策略分析
(1)风险预防策略：慢病人群吸烟率(18.98%)、过量饮酒率(16.98%)略高于总样本人群的平均水平(18.28%、14.40%)；慢病家庭环境卫生状况次于样本家庭,自来水普及率(76.88%)、清洁能源普及率(47.43%)均低于样本家庭平均水平(78.35%、52.95%)；调查前一年样本人群中仅有29.06%(1005人)的调查对象接受过新农合的免费体检,慢病人群的体检率为33.21%,尚不足三分之一。
(2)风险缓和策略：慢病家庭的收入来源多样化指数(0.570)略低于总样本家庭(0.585)；慢病家庭的物质资本和人力资本储备能力低于总样本家庭,有存款的慢病家庭比例(34.21%)低于总样本家庭(36.59%),慢病家庭的平均人口数略高于总样本家庭,而其劳动年龄人口数和自感健康状况较好者的人数均低于总样本家庭；过去一年慢病病例的治疗率为88.23%,自我医疗率为48.17%,未治疗率为11.77%；有慢病患者的家庭参合率为99.06%,略高于总样本家庭(98.48%)。
72.62%的慢病病例得到了新农合的补偿,新农合对慢病治疗费用的实际补偿比为10.42%；新农合补偿使4.77%的慢病病例摆脱了高风险状态,高经济风险发生率下降程度为9.49%；新农合补偿使3.20%的慢病家庭摆脱了灾难性卫生支出,灾难性卫生支出发生率的下降程度为15.47%,平均差距、相对差距分别下降了1.44和6.95个百分点,下降程度为13.97%。
(3)风险应对策略：利用自己家庭的现金或存款(非正式机制)是慢病病例及其家庭应对慢病治疗费用的主要策略(96.78%),其他正式和非正式应对策略的利用比例均不到5%。患者家庭自付费用是慢病治疗费用的最主要来源,占全部治疗费用的77.13%,其次,11.29%的慢病治疗费用来自于社会网络(主要是亲戚朋友)的馈赠和借款；而正式应对机制(医疗救助补贴和银行贷款)分担的比例不足3%。
结论与政策建议
本研究对样本地区农村居民慢病经济风险产生路径的各个环节(慢病患病、治疗及费用的情况)及其影响因素、慢病病例和家庭的疾病经济风险水平及影响因素以及慢病经济风险的管理策略进行了分析,发现：样本地区农村居民慢病患病率、治疗率高(但自我医疗率高)、慢病治疗费用及其给慢病患者和家庭造成的经济风险高；年龄高、过量饮酒是慢病患病的危险因素,高受教育程度和高收入是保护因素；自感健康状况和系统疾病的种类是影响慢病治疗概率和治疗费用的显著因素,卫生服务可及性也是慢病治疗率的影响因素,经济困难是造成居民未就诊和未住院的重要原因；高收入是慢病病例经济风险高低的保护因素,住院治疗是危险因素,自感健康状况和系统疾病的种类也是影响慢病病例经济风险高低的显著因素；而家庭收入、家庭总人口数、家中慢病患者人数、家中是否有慢病患者住院、户主职业是影响慢病家庭灾难性卫生支出发生概率的显著因素。样本地区慢病病例及其家庭的慢病经济风险管理策略中,对预防策略重视程度不够；缓和策略作用有限,其中正式风险缓和机制——新农合制度的补偿对减轻慢病病例及其家庭经济风险的能力不足；风险应对策略以非正式机制为主,其中,家庭现金卫生支出是最主要的于段。
基于上述结论,提出慢病经济风险预防、缓和与应对的三级管理模式：风险预防：(1)加强慢病相关知识宣传教育,倡导积极健康的生活方式,最大限度地降低各种慢病的患病率,从根本上预防慢病导致的经济风险；(2)将健康体检等预防保健服务纳入新农合补偿范围,建立健康档案,对慢病患者进行系统管理,防止病情加重、预防并发症的发生。
风险缓和：(1)继续扩大新农合覆盖面,进一步提高新农合筹资水平,改变“先垫付、后报销”的程序；(2)将慢病逐步纳入新农合大病统筹,进一步提高慢病住院补偿标准；(3)引导患者积极合理就医,充分利用基层卫生服务机构,降低慢病治疗花费；(4)鼓励以市场为基础的商业医疗保险在农村地区的发展；(5)鼓励农村居民从事多种收入活动,增加家庭收入以实现缓和、分散慢病经济风险的目的。
风险应对：(1)实现医疗救助制度与新农合制度的协同发展和有效衔接；(2)促进农村地区信贷机构等正式风险应对机制的发展；(3)进一步发挥社会网络等非正式风险应对机制的作用。
Background
As the development of social economy and the improvement of living standard, the changes in life style and diet structure, environmental deterioration, accelerating ageing etc. bring about significant changes in the spectrum of diseases in our country. Non-communicable chronic diseases (NCDs) are becoming the main threat to the health of rural residents. In2008, the number of chronic cases was260million and was increasing by10million new cases each year. Among them, cases with hypertension and diabetes increased by2times. Due to high prevalence, multi-complications, long duration of treatment and bad prognosis, NCDs patients and families need to pay substantial medical expenses, resulting in heavy economic burdens. The World Health Organization estimated that the direct medical expenses will exceed500billion US Dollars. Especially for rural households, NCDs'medical expenditure increases much faster than their income, which further magnifies economic shocks of disease risk towards rural residents, so that their families face tremendous NCDs'financial risk. Against this risk, rural residents and their households have already formed a serious of risk management strategies, one of which is rural cooperative medical care system (NCMS), the principal medical scheme in rural areas. Its core function is to protect farmers from being inflicted by disease financial risk.
The generation and development of the disease financial risk is a successive process, which will be affected by all kinds of risk factors in this process, so that researches on disease financial risk and its management should be based on this whole process. However, most researches on disease financial risk management stand in the perspective of responding after risk happened. So far, there has been no systematic research on the generating path, level, distribution and determinants of rural resident and their households'financial risk due to NCDs, as well as influencing factors on each part of the whole process. Besides, it lacks empirical analysis of NCD's financial risk management strategies from risk prevention, mitigation and coping with the application of Social Risk Management framework.
At the background of continuously increasing NCDs prevalence and medical expenses in rural areas of our country, inadequacy of capacity to respond to disease financial risk, and farmers'being into or back into poverty by illness, it's of great significance to explicit generating path of rural resident's NCDs financial risk, measure financial risk level resulted by NCDs, analyze influencing factors on risk and inspect the risk management strategies of rural residents/households, NCMS's function to reduce disease financial risk in particular.
Objectives
General objective of this study is to systematically research on rural residents'NCDs financial risk, disentangle its generating path, explicit its level and influencing factors among rural residents and their households by means of reviewing, summarizing domestic/abroad research results and analyzing data from field survey, in order to propose policy implications reducing rural residents'financial risk due to NCDs. Specific objectives includes:to build the theoretical framework of NCDs financial risk's generating path and its management; to analyze the influencing factors of each part of this path, to measure the level of rural residents and their households'financial risk due to NCDs, explore the determinants of NCDs financial risk; investigate NCDs financial risk management strategies of rural residents, especially NCMS's function to reduce risk; to make policy suggestions for managing rural residents'NCDs financial risk.
Data and Methods
The data source of this study relied mainly on literature review and field investigation. Through the review of the literature, this analysis introduced the concept of financial risks due to NCDs, summarized its commonly used evaluation indicators and summed up the affecting factors and analytical methods. In addition, the study proposed the theoretical framework of generation path and risk management of the NCDs based on the conceptual frame of social risk management. The study employed a stratified random sampling method, with3counties of Jinan selected. Within each county,18villages spread across3townships were selected to participate in the survey. About20households were randomly selected per village, resulting in a total sample of3458rural residents in984households as respondents. This survey mainly included family general information, basic situation of family members and situation of health service demand and utilization of chronic diseases of the previous year before survey. Data analysis methods were mainly descriptive analysis, univariate analysis and multivariate analysis (including Two-part model, Non-conditional Binary Logistic regression analysis, Multivariate Linear Regression Analysis). The Statistical analysis software used was SPSS15.0for windows.
Results
1. Rural Residents'NCDs Prevalence, Treatment, Costs and their Determinants The prevalence rates calculated on the basis of number of NCDs patients and number of cases was19.38%and23.34%, respectively, both of which were higher than the NCDs prevalence rate from the national health services survey in2008. Rural residents in the sampled areas were facing higher risk of NCDs. Circulatory system diseases were the most important constitute of NCDs among sampled population (47.21%), in which the prevalence rate of hypertension was the highest. Multivariate analysis of NCDs prevalence rate indicated that advanced age and alcohol abusing were risk factors, while higher income, higher education level were protective factors. During the year before survey, the treatment rate of NCDs cases was88.23%, self treatment rate was48.17%, non-treatment rate was11.77%, and the rate of non-hospitalization was1.73%. Financial hardship is the main factor of non-treatment and non-hospitalization for chronic cases. The average annual treatment costs on NCDs was1534.79RMB, among which per capita inpatient and outpatient treatment cost were648.75and624.44RMB, respectively, while the medicine cost in drugstore was the least (261.60RMB).
The two-part model analysis of NCDs treatment rate and cost indicated that perceived health status and the type of system diseases were significant affecting factors. The treatment rate and cost of patients whose perceived health status was poorer were higher than those with better health status. The treatment rate and cost in circulatory system diseases, digestive system diseases, endocrine system disease and other system diseases were higher than musculoskeletal system diseases and connective tissue diseases. In addition, health service accessibility (whether the nearest medical institution was within200meters) had a significant effect on the NCDs treatment rate, while no significant effect on the treatment cost.
2. Rural Residents'Financial Risk due to NCDs and its Determinants
(1) Financial risk of chronic cases and their families
The income of chronic patients and their families was lower than the average level of the sample while health expenditure was higher than the average. The relative financial risk of chronic cases is2.50times of the total sample (adjusted RR=2.50), and the low-income group had the highest relative risk (adjusted RR=5.71). During the past year,50.28%of the chronic cases who had treatment were in the higher financial risk due to costs of treatment;20.68%of the households with chronic patients had experienced catastrophic health payments due to the cost of NCDs treatment, while the mean gap and mean positive gap were10.28%and49.73%, respectively, the concentration index of catastrophic health payments was-0.314, which indicated that catastrophic health payments were more likely to occur in families with lower income.
(2) Determinants of financial risk of chronic patients and their family
Multivariate analysis showed that income, perceived health status, hospitalization and the category of diseases are significant factors influencing NCDs cases'financial risk. The probability of higher financial risk decreased with the increase of income; cases with worse and normal perceived health status have higher probability of financial risk than better health status (Odds Ratio=2.256). Cases who had hospitalization in the past year had higher probability than non-hospitalization cases. The probability is significantly different among different types of system diseases, and cases with musculoskeletal system and connective tissue diseases had lower risk. Significant factors influencing the probability of catastrophic health expenditures in households with chronic patients were the household's total population, the number of chronic patients in the family, whether hospitalized or not, household income, county and the occupation of the household head. Headcount of catastrophic health payments decreased with the increase of the household's total population and income, and increased with the number of chronic patients in households. Those households with patients who had hospitalized in the past year had higher probability of catastrophic health payments. The incidence of catastrophic health expenditures was different among counties and Zhangqiu had the lowest incidence. Those households which the head of household is farmer had higher incidence than non-farmers.
3. Rural Residents'Risk Management Strategies of Financial Risk due to NCDs
(1)Risk Prevention Strategies:smoking rate of NCDs cases (18.98%) and excessive alcohol consumption rate (16.98%) was slightly higher than the average rate of sample population (18.28%,14.40%). Sanitation situation of households with NCDs cases was inferior to that of sample households. Proportion of tap water (76.88%) and clean energy (47.43%) of households with NCDs was lower than sample households. During the year before the survey, only29.06%(1005) of the sampled population and33.21%of NCDs cases received free medical examination from NCMS.
(2)Risk Mitigation Strategies:Income resource diversification index of households with NCDs (0.570) was slightly lower than that of sampled households (0.585).The proportion of chronic disease household with deposit (34.21%) was lower than that of sample households (36.59%). The average household population of households with NCDs was slightly higher than that of sample households, but the number of working age population and the self-inductance of health status was lower than that of sampled households. Treatment of chronic disease cases in the past year was88.23%, self-medication was48.17%, no treatment was11.77%; the rate of chronic disease families joining NCMS was99.06%, slightly higher than that of sample households (98.48%).72.62%of the cases were compensated by NCMS, the actual compensation rate of NCMS was10.42%; NCMS made4.77%of cases of chronic disease get rid of the high-risk status, the degree of incidence of high economic risk level decreased by9.49%;the NCMS compensation let3.20%of chronic disease families flee from catastrophic health expenditure, and the incidence of catastrophic health expenditure dropped by15.47%, the average gap and the relative gap declined by1.44%and6.95%, respectively, a drop of13.97%.
(3)Risk Coping Strategies:Using cash or deposits of their own family (informal mechanisms) was the main strategy of households with NCDs patients to cope with NCDs treatment costs (96.78%of households with NCDs paid for medical expenses by cash or deposit), the use of other formal and informal coping strategies was less than5%. The main source of NCDs treatment costs was Out-of-pocket of the households, accounting for77.13%of total costs. Only3%of the costs were from the formal risk coping mechanism, including medical assistance and commercial insurance.
Conclusions and Policy Implications
Rural residents'NCDs prevalence rates and treatment rates were higher in the sample region. NCDs treatment costs and its financial risks to NCDs cases and families were high; Advanced age, excessive drinking were risk factors of NCDs prevalence; Higher education level and higher income were protective factors; Perceived health status and types of system disease were significant factors which affected NCDs treatment probability and costs; Health service accessibility was also affecting factor of NCDs treatment rates, and economic hardship was an important reason for NCDs cases not to use health services. Income level, whether using hospitalization services, perceived health status and types of system disease were significant factors affecting chronic cases'financial risk; While household income, the household's total population, the number of NCDs patients, whether there were hospitalized patients in the household and the career of householders were significant factors of the probability of households'catastrophic health expenditure. As to rural residents'financial risk management strategies for chronic disease, prevention strategies were not emphasized, mitigation strategies had a limited effect, and the compensation capacity of NCMS, which is the main formal means in coping strategies, is inadequate for sharing the NCDs cases of and their families'financial risk. Based on the above findings, we propose a three-level management model for NCDs financial risk which includes prevention, mitigation and coping strategies:
Risk prevention:(1) to strengthen publicity and education of chronic disease-related knowledge, to promote active and healthy lifestyle to minimize the prevalence of NCDs, to fundamentally prevent financial risks caused by NCDs;(2) to include physical examination in NCMS compensation range, to conduct physical examination for residents and establish health records, and undergo systematic management for chronic patients, to prevent exacerbations and prevent complications.
Risk mitigation:(1) to continue to expand the NCMS coverage, further improve the NCMS funding levels, and change the "first pay, then get reimbursement" process;(2) to gradually incorporate NCDs into NCMS arrangement for serious diseases, to further improve the standard of chronic disease hospital compensation;(3) to guide patients to a reasonable medical treatment, full use of primary health services, reduce chronic disease treatment costs;(4) to promote the development of formal mitigation mechanisms based on market, e.g. commercial insurance;(5) to encourage rural residents to engage in multiple income sources and increase their income to disperse financial risk due to NCDs.
Risk coping:(1) to fulfill the joint development and effective interface of medical assistance system and NCMS;(2) to promote the development of formal coping mechanisms based on market, e.g. credit institutions;(3) to expand the role of informal risk-coping mechanisms of social networks.
引文
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