新型农村合作医疗制度下安徽省部分地区药品费用影响因素与控制策略研究
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摘要
目的:本研究旨在了解安徽省农村地区住院病人费用的构成情况,探寻不合理使用药品造成的不必要费用的严重程度及其主要影响因素,为农村卫生管理部门制定合作医疗相关政策及药物政策提供现实依据,促进合理用药政策的有效实施和可持续发展。
方法:本研究综合采用文献法、现场调查法、专家咨询法、统计学方法等多种方法进行研究。收集的资料包括:(1)国内外合理用药及费用控制研究的文献资料;(2)5个新型农村合作医疗试点县基本情况调查资料:包括人口状况、宏观经济状况、地区卫生系统的财政状况;(3)新型农村合作医疗定点机构调查资料:安徽省5个县的20个医疗机构(其中包括10个县级医疗机构和10个乡级医疗机构)2005年至2006年阑尾炎、子宫肌瘤、胆囊炎、脑梗塞、肺炎、消化性溃疡患者的住院病历和药品费用清单。
研究内容包括:(1)安徽省新型农村合作医疗定点机构住院病人医疗费用构成研究:(2)农村地区住院病人药品费用影响因素研究:(3)药品费用控制措施及策略研究。
结果:通过对本次调查资料的汇总,使用统计学方法计算均数和构成比,发现安徽省新型农村合作医疗定点机构住院病人医疗费用的主要构成为:药费43.57%,手术费19.47%,诊疗费16.20%.
被调查农村地区卫生管理部门采取的以临床诊疗规范和以基本药物目录为基础的安徽省新型合作医疗药品报销目录等措施已经取得了一定的效果。本次调查的合作医疗试点地区目录内用药的比例平均为96.35%,非试点地区目录内用药比例平均为94.21%,低于合作医疗的试点地区。试点地区中参加合作医疗的人群药品费用为946.93元,目录内用药比例为95.64%,未参加合作医疗的人群药品费用为661.13元,目录内用药比例为97.91%,略高于未参加合作医疗的人群。这表明新型农村合作医疗政策的实施在一定程度上改变了被调查地区医疗服务供方的药品使用行为,但是医疗机构的行为不受群众支付方式的影响,或者这种由合作医疗的报销制度导致的不合理支出并不明显。同时被调查地区的乡级医疗机构平均药品费用为639.4元,县级医疗机构平均药品费用为1046.9元,显著高于乡级医疗机构的平均药品费用。
过度用药和重复用药的情况主要存在于县级医疗机构,而在乡镇卫生院的不规范医疗服务行为中较多存在的是无明显疗效、用药不足、不科学配伍的情况。
在本次研究选取的疾病中,不合理费用产生比例较大的病种有脑血栓,其次是肺炎和胆囊炎。在脑血栓患者的治疗中,使用的新药品种较多,且很多在合作医疗基本药物目录之外,各品种价格差异较大,不合理费用也较大。
逐步回归分析在8个可能影响住院药品费用的因素中5个自变量被筛选入回归方程,即对因变量有显著影响。这些因素对住院费用的影响由大到小依次为住院天数、医疗机构级别、诊断疾病、地区经济指数和性别,其标准化回归系数分别为0.410、0.227、0.106、0.077、0.065。
药品从投入生产到消费者购买的过程中,所经历的价格大致分为成本、出厂价、实际价、批发价(中标价)和零售价。我国大部分药品都是仿制药品,其生产成本和研发成本较低,而药品的流通成本、采购成本和使用成本偏高导致了“药品价格虚高”。
结论:(1)进一步增加对卫生事业的投入,尤其是加强对基层医疗机构的补偿力度;(2)科学合理的制定收费标准,健全合作医疗中各级医院间的转诊制度;(3)重点开展高负担疾病常见并发症的预防控制工作;(4)在乡级医疗机构中,重点加强药品法规和合理使用方面的教育培训,提高人员的业务素质;(5)在县级医疗机构中,重点加强药品使用方面的监管并对定点医疗机构的合理用药采取有效的激励措施;(6)整顿医药市场价格秩序,提高药品定价的科学性和透明度;(7)保证基本用药目录内的药品的定点供应,减少流通环节;(8)医药联动,完善国家基本药物的录入和使用。
Object:This study investigated the construction of medicine cost in rural areas of Anhui.This study is also explored certain facts influencing the change of expenses and their degrees respectively,in order to control the unreasonable increase of expenses. This study provided some suggestions on the national drug policies and policies of New-type rural cooperation medical system,in order to improve rational use of drugs in rural areas and ensure the ration use of drugs policy be effective in a sustainable way.
Data and Methods:Literature review,field investigation,expert consultation and statistical method were used in this study.The data included:(1) Literatures of hospitalization cost control in China and abroad.(2)Comprehensive date on counties which with the policy of New-type rural cooperation medical system,including:date of local population,situation of macroscopic economy、financial situation of local system of health management.(3) The data of New-type rural cooperative medical system experimental countries,including the data of inpatient medical record and list of medical cost of 20 health facilities in 5 project counties from 2005 to 2006.We selected 984 cases of Appendicitis,Hysteromyoma tumor,Cholecystitis,Cerebral thrombosis,Pneumonia and Alimentary canal canker as sample and using factor analysis to study expenses result factors.
Result:Residential day is proved to be the main factor of expenses.Suggestion:To control the residential day promptly and scientifically and to prevent syndrome of more common diseases.
This study content included:(1) study on component of hospitalization cost in New-type rural cooperative medical system experimental institution.(2) Analysis on influencing factors of hospitalization cost.(3) Study on strategies to apply interventions.
Results and Conclusions.1.By reviewing and summarizing the literatures and date of this investigation,analyzing the mean,median,stranded deviation of every indicator, the researcher found component of hospitalization cost in New-type rural cooperative medical system experimental institution is as follows:cost of drug 43.57%,cost of surgery 19.47%,cost of cure 16.20%.
2.The health administrations in the investigated area have taken some methods,such us standard treatment guideline(STG),essential drug list(EDL) of Anhui New-tape cooperative medical care system(CMS).And it have some rational effect.According to the result of the investigation,in the experimental areas,percentage of essential drugs is up to 96.35%in average.Meanwhile,in the other areas,the percentage is only 94.21%. In the experimental areas,percentage of essential drugs of the patient who participated in the New-tape cooperative medical care system is up to 95.64%.Those was not involved in New-tape cooperative medical care system only has a percentage of 97.91% in average.It is a little larger rate compared to the people of CMS,but statistically,it is not a significant difference.The result indicated that the application of the CMS policy have changed the conduction of drug use in investigated areas to some extent,but the conduction of medical institution has not changed according to payment form of patients.In another words,it have not enough evidence to say the compensation system in CMS lead to irrational expenditures in patients cost.The drug cost in the medical institutions of county class is RMB 1046.9 yuan in average,which is much more than in those of rural class,RMB 639.4 yuan in average. level.However,behavior of irrational use of drugs happened in medical facilities at town level concern more about being withno obvious effect,using medicine deficiency, irrational match of drugs.
That unreasonable cost mostly increased in the patients suffering with cerebral thrombosis,those patients with pneumonia and cholecystitis follows.In treating the cerebral thrombosis patient,there are abundant new medicines to be selected,and many of them are not in the drug catalogues of cooperative medical care.And there are more difference in its price,in the end lead to a more unreasonable cost.
4.The result of step-by-step regression analysis shows that 5 independent variables are entered the equation,which reflected the facts out of 8 independent variables are affected the hospitalization cost.According to the distance of influence,the effect cost arrives as follows,days living in hospital,rank of medical institution,kind of disease, economic index in the area and sex of patient,the standardizes return modulus being 0.410,0.227,0.106,0.077,0.065 respectively.
5.From factories to customers,the price of medicine can be summarized as the cost price,leave factory price and throwing into price(is hit by catalogue),actual price, wholesale price and retail price.Most medicines and chemical reagents of our country all is to copy medicines and chemical reagents,whose cost of production and research cost are comparatively low,but medicines and chemical reagent's circulating cost, purchasing cost and using cost is much higher,and as a result led to the high price of medicines and chemical reagents.
Suggestions:
1 Increases the government's investment,reinforces to the strength that supporting the medical institutions at county level and town level.
2.Make the reimbursing percentage reasonable and work out the policy to make it more easy for patients to change to another medical institution.
3.Taking precautions action against the disease which leading to a height cost and with a high occurrence ratio in population.
4.Reinforce the education of medicines and chemical reagents regulation and training of rational drug use,improves business of medical establishment personnel ability.
5.Put medicine price system in good order;improve medicines and chemical reagents make chemical reagents price in a scientific and transparency way.
6.Guarantee the medicine in the basic drug content to be supplied by the pointed manufactories and reduce the stages in delivery.
7.The policies of health care and the policies of medicine are innovated mutually;to optimize the registration and uses of the basic medicine.
方法:本研究综合采用文献法、现场调查法、专家咨询法、统计学方法等多种方法进行研究。收集的资料包括:(1)国内外合理用药及费用控制研究的文献资料;(2)5个新型农村合作医疗试点县基本情况调查资料:包括人口状况、宏观经济状况、地区卫生系统的财政状况;(3)新型农村合作医疗定点机构调查资料:安徽省5个县的20个医疗机构(其中包括10个县级医疗机构和10个乡级医疗机构)2005年至2006年阑尾炎、子宫肌瘤、胆囊炎、脑梗塞、肺炎、消化性溃疡患者的住院病历和药品费用清单。
研究内容包括:(1)安徽省新型农村合作医疗定点机构住院病人医疗费用构成研究:(2)农村地区住院病人药品费用影响因素研究:(3)药品费用控制措施及策略研究。
结果:通过对本次调查资料的汇总,使用统计学方法计算均数和构成比,发现安徽省新型农村合作医疗定点机构住院病人医疗费用的主要构成为:药费43.57%,手术费19.47%,诊疗费16.20%.
被调查农村地区卫生管理部门采取的以临床诊疗规范和以基本药物目录为基础的安徽省新型合作医疗药品报销目录等措施已经取得了一定的效果。本次调查的合作医疗试点地区目录内用药的比例平均为96.35%,非试点地区目录内用药比例平均为94.21%,低于合作医疗的试点地区。试点地区中参加合作医疗的人群药品费用为946.93元,目录内用药比例为95.64%,未参加合作医疗的人群药品费用为661.13元,目录内用药比例为97.91%,略高于未参加合作医疗的人群。这表明新型农村合作医疗政策的实施在一定程度上改变了被调查地区医疗服务供方的药品使用行为,但是医疗机构的行为不受群众支付方式的影响,或者这种由合作医疗的报销制度导致的不合理支出并不明显。同时被调查地区的乡级医疗机构平均药品费用为639.4元,县级医疗机构平均药品费用为1046.9元,显著高于乡级医疗机构的平均药品费用。
过度用药和重复用药的情况主要存在于县级医疗机构,而在乡镇卫生院的不规范医疗服务行为中较多存在的是无明显疗效、用药不足、不科学配伍的情况。
在本次研究选取的疾病中,不合理费用产生比例较大的病种有脑血栓,其次是肺炎和胆囊炎。在脑血栓患者的治疗中,使用的新药品种较多,且很多在合作医疗基本药物目录之外,各品种价格差异较大,不合理费用也较大。
逐步回归分析在8个可能影响住院药品费用的因素中5个自变量被筛选入回归方程,即对因变量有显著影响。这些因素对住院费用的影响由大到小依次为住院天数、医疗机构级别、诊断疾病、地区经济指数和性别,其标准化回归系数分别为0.410、0.227、0.106、0.077、0.065。
药品从投入生产到消费者购买的过程中,所经历的价格大致分为成本、出厂价、实际价、批发价(中标价)和零售价。我国大部分药品都是仿制药品,其生产成本和研发成本较低,而药品的流通成本、采购成本和使用成本偏高导致了“药品价格虚高”。
结论:(1)进一步增加对卫生事业的投入,尤其是加强对基层医疗机构的补偿力度;(2)科学合理的制定收费标准,健全合作医疗中各级医院间的转诊制度;(3)重点开展高负担疾病常见并发症的预防控制工作;(4)在乡级医疗机构中,重点加强药品法规和合理使用方面的教育培训,提高人员的业务素质;(5)在县级医疗机构中,重点加强药品使用方面的监管并对定点医疗机构的合理用药采取有效的激励措施;(6)整顿医药市场价格秩序,提高药品定价的科学性和透明度;(7)保证基本用药目录内的药品的定点供应,减少流通环节;(8)医药联动,完善国家基本药物的录入和使用。
Object:This study investigated the construction of medicine cost in rural areas of Anhui.This study is also explored certain facts influencing the change of expenses and their degrees respectively,in order to control the unreasonable increase of expenses. This study provided some suggestions on the national drug policies and policies of New-type rural cooperation medical system,in order to improve rational use of drugs in rural areas and ensure the ration use of drugs policy be effective in a sustainable way.
Data and Methods:Literature review,field investigation,expert consultation and statistical method were used in this study.The data included:(1) Literatures of hospitalization cost control in China and abroad.(2)Comprehensive date on counties which with the policy of New-type rural cooperation medical system,including:date of local population,situation of macroscopic economy、financial situation of local system of health management.(3) The data of New-type rural cooperative medical system experimental countries,including the data of inpatient medical record and list of medical cost of 20 health facilities in 5 project counties from 2005 to 2006.We selected 984 cases of Appendicitis,Hysteromyoma tumor,Cholecystitis,Cerebral thrombosis,Pneumonia and Alimentary canal canker as sample and using factor analysis to study expenses result factors.
Result:Residential day is proved to be the main factor of expenses.Suggestion:To control the residential day promptly and scientifically and to prevent syndrome of more common diseases.
This study content included:(1) study on component of hospitalization cost in New-type rural cooperative medical system experimental institution.(2) Analysis on influencing factors of hospitalization cost.(3) Study on strategies to apply interventions.
Results and Conclusions.1.By reviewing and summarizing the literatures and date of this investigation,analyzing the mean,median,stranded deviation of every indicator, the researcher found component of hospitalization cost in New-type rural cooperative medical system experimental institution is as follows:cost of drug 43.57%,cost of surgery 19.47%,cost of cure 16.20%.
2.The health administrations in the investigated area have taken some methods,such us standard treatment guideline(STG),essential drug list(EDL) of Anhui New-tape cooperative medical care system(CMS).And it have some rational effect.According to the result of the investigation,in the experimental areas,percentage of essential drugs is up to 96.35%in average.Meanwhile,in the other areas,the percentage is only 94.21%. In the experimental areas,percentage of essential drugs of the patient who participated in the New-tape cooperative medical care system is up to 95.64%.Those was not involved in New-tape cooperative medical care system only has a percentage of 97.91% in average.It is a little larger rate compared to the people of CMS,but statistically,it is not a significant difference.The result indicated that the application of the CMS policy have changed the conduction of drug use in investigated areas to some extent,but the conduction of medical institution has not changed according to payment form of patients.In another words,it have not enough evidence to say the compensation system in CMS lead to irrational expenditures in patients cost.The drug cost in the medical institutions of county class is RMB 1046.9 yuan in average,which is much more than in those of rural class,RMB 639.4 yuan in average. level.However,behavior of irrational use of drugs happened in medical facilities at town level concern more about being withno obvious effect,using medicine deficiency, irrational match of drugs.
That unreasonable cost mostly increased in the patients suffering with cerebral thrombosis,those patients with pneumonia and cholecystitis follows.In treating the cerebral thrombosis patient,there are abundant new medicines to be selected,and many of them are not in the drug catalogues of cooperative medical care.And there are more difference in its price,in the end lead to a more unreasonable cost.
4.The result of step-by-step regression analysis shows that 5 independent variables are entered the equation,which reflected the facts out of 8 independent variables are affected the hospitalization cost.According to the distance of influence,the effect cost arrives as follows,days living in hospital,rank of medical institution,kind of disease, economic index in the area and sex of patient,the standardizes return modulus being 0.410,0.227,0.106,0.077,0.065 respectively.
5.From factories to customers,the price of medicine can be summarized as the cost price,leave factory price and throwing into price(is hit by catalogue),actual price, wholesale price and retail price.Most medicines and chemical reagents of our country all is to copy medicines and chemical reagents,whose cost of production and research cost are comparatively low,but medicines and chemical reagent's circulating cost, purchasing cost and using cost is much higher,and as a result led to the high price of medicines and chemical reagents.
Suggestions:
1 Increases the government's investment,reinforces to the strength that supporting the medical institutions at county level and town level.
2.Make the reimbursing percentage reasonable and work out the policy to make it more easy for patients to change to another medical institution.
3.Taking precautions action against the disease which leading to a height cost and with a high occurrence ratio in population.
4.Reinforce the education of medicines and chemical reagents regulation and training of rational drug use,improves business of medical establishment personnel ability.
5.Put medicine price system in good order;improve medicines and chemical reagents make chemical reagents price in a scientific and transparency way.
6.Guarantee the medicine in the basic drug content to be supplied by the pointed manufactories and reduce the stages in delivery.
7.The policies of health care and the policies of medicine are innovated mutually;to optimize the registration and uses of the basic medicine.
引文
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[28]国家发展计划委.计价格[2001]13号.国家计委关于单独定价药品价格制定有关问题的通知[Z].2001-01-04.
[29]国家发展改革委.发改价格[2005]9号.国家发展改革委关于印发《药品差比价规则(试行)》的通知[Z].2005-01-07.
[30]国家药品监督管理局执业药师资格认证中心.药事管理与法规[M].第4版.北京:中国中医药出版社,2006:142-145.
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[35]赵晶,金进.社会药学[M].昆明:云南科技出版社,2001:293
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[1]王青,兰奋,肖爱丽.不合理用药问题及干预研究,中国临床药理学杂志,2003,19(1):75-78
[2]赵郁馨,万泉,陶四海等.中国卫生总费用测算结果与分析.2002中国卫生经济,2004,23(3):5-9.
[3]赵郁馨1999年中国卫生总费用测算报告 中国卫生经济.2001,20(9):9-13.
[4]赵郁馨,万泉,高广颖等2001年中国卫生总费用测算与分析,2003,22(3):1-3.
[5]汪光宝,张震巍.WHO促进合理用药的核心政策[J].医院管理论坛,2003(6):38
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[9]卢凤霞.根治药品价格虚高还需猛药[J].中国药业年2005,14(7):2-3
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[13]钟梅.介评,促进发展中国家合理用药的十项建议[J].药事管理,2002(2): 36-37
[14]杨樟卫,胡晋红,宋功成.临床用药辅助决策系统对合理用药的影响及其经济学评价方法[J].中国药房,2006,17(5):385-386
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[17]陈长生.对合理控制医疗费用的思考[J].卫生经济研究2005,10(7):23
[18]郑建刚,袁兆康 等.新农合对农民医疗费用影响的五年连续追踪研究[J].中国农村卫生事业管理2008,2(28):91-93
[19]陈盛新,蒯丽萍.国家药物政策的概念与实践[J].药学实践杂志2007,25(5):348-351
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[1]王青,兰奋,肖爱丽.不合理用药问题及干预研究,中国临床药理学杂志,2003,19(1):75-78
[2]赵郁馨,万泉,陶四海等.中国卫生总费用测算结果与分析.2002中国卫生经济,2004,23(3):5-9.
[3]赵郁馨1999年中国卫生总费用测算报告 中国卫生经济.2001,20(9):9-13.
[4]赵郁馨,万泉,高广颖等2001年中国卫生总费用测算与分析,2003,22(3):1-3.
[5]汪光宝,张震巍.WHO促进合理用药的核心政策[J].医院管理论坛,2003(6):38
[6]万伟忠.药品费用增长过快的原因与控制措施[J].医药论坛,2006,3(13):96-97
[7]卫生部统计信息中心 中国卫生统计年鉴2004.www.moh.gov.cn
[8]孙家跃.医院不合理用药现状分析及对策[J].安徽医药2005,9(10):785-786
[9]卢凤霞.根治药品价格虚高还需猛药[J].中国药业年2005,14(7):2-3
[10]谢先德.试论农村药品监管及供应问题[J].中国药事2005,19(1):21-22
[11]Society for Healthcare Epidemiology of America and Infection Diseases Society of America Joint Committee on the Prevention of antimicrobial Resistance.Guideline for the Prevention of antimicrobial Resistance in hospitals J.Infect Control Hosp Epidemil,1997,18:275
[12].Mason WH.Strategies to promote appropriate anti microbial use J.Pediatr Infect Dis J,1998,17(8):747
[13]钟梅.介评,促进发展中国家合理用药的十项建议[J].药事管理,2002(2): 36-37
[14]杨樟卫,胡晋红,宋功成.临床用药辅助决策系统对合理用药的影响及其经济学评价方法[J].中国药房,2006,17(5):385-386
[15]邓晨珂.药价虚高的经济学分析及对策研究[J].药品评价,2006,3(2):94-95
[16]李士雪,杨金侠.对新型农村合作医疗定点医疗机构实施监管的主体、策略及控制方法[J].中国卫生经济2006.3(25):43-44
[17]陈长生.对合理控制医疗费用的思考[J].卫生经济研究2005,10(7):23
[18]郑建刚,袁兆康 等.新农合对农民医疗费用影响的五年连续追踪研究[J].中国农村卫生事业管理2008,2(28):91-93
[19]陈盛新,蒯丽萍.国家药物政策的概念与实践[J].药学实践杂志2007,25(5):348-351
[20]孟锐.国家基本药物政策实效弱化的后果分析与强化推行的对策探讨[J].中国药房,2006;17(8):564.
[21]World Health Organization.How to develop and implement a natinal drug policy[M].Geneva,2004.
[22]World Health Organization.Using indicators to measure county pharmaceutical situations[M].Geneva,2006.
[23]胡善联.我国新型农村合作医疗制度的运行状况与评价分析[J].中国卫生经济2008,27(300):26-27
[24]袁兆康.方丽霖,周小军等.新型农村合作医疗制度对农民医疗费用影响的追踪调查[J]中国农村卫生事业管理,2006.26(10):17-20.
[25]袁兆康,方丽霖,周小军,等.新型农村合作医疗制度对农民医疗费用的影响研究[J].中国农村卫生事业管理,2005.25(5):11-13.
[26]马月丹,于娣,胡冬梅,姜潮.医院药品费用控制政策的发展历程现代医院管理2007,(21):21-23
[27]杨金侠,王禄生.新型农村合作医疗实施混合支付方式的构想[J].卫生经济研究.2006,(3):5-8
[28]杨金侠,江启成,李士雪,李林贵.新型合作医疗机构管理对策探讨[J].中国医院管理2005,25(8):57-58
[29]保障公众用药安全,促进药品的可获得性-关于中国药物政策的有关问题[J].中国药事,2005;19(8):451.