山东省新型农村合作医疗重大疾病医疗保险运行模式研究
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摘要
研究背景:
     新型农村合作医疗制度是我国政府为提高农村居民的健康和医疗保障水平而进行的积极探索。近年来,随着人口老龄化和疾病谱的变化,重大疾病对健康和社会发展的影响日益明显,农村地区尤为严重。而新型农村合作医疗因其“低水平、广覆盖”的制度设计理念,筹资和保障水平相对较底,对重大疾病风险的保障十分有限。2009年深化医药卫生体制改革启动后,国家加大了医疗保障体系建设力度,各级政府对新型农村合作医疗补助标准大幅度增加。随着新型农村合作医疗筹资水平越来越高,探索研究在新型农村合作医疗制度中构建重大疾病医疗保险运行模式,逐步开展新型农村合作医疗重大疾病医疗保险工作,对进一步提高参合农民保障水平、减轻农村重大疾病患者医疗费用负担、巩固发展新型农村合作医疗制度、推动医改工作不断走向深入具有重大意义。
     研究目的:
     本研究的目的是探索构建山东省新型农村合作医疗重大疾病医疗保险运行模式。具体目的如下:1)重大疾病内涵与重大疾病医疗保险理论研究。2)我国新型农村合作医疗制度运行现状分析。3)开展新型农村合作医疗重大疾病医疗保险工作的必要性分析。4)在山东省构建新型农村合作医疗重大疾病医疗保险运行模式的可行性分析。5)探索构建山东省新型农村合作医疗重大疾病医疗保险运行模式。
     研究方法:
     在研究的不同阶段,根据不同研究目的和内容,分别采用不同的方法:
     1)研究初步阶段。采用文献复习法,通过比较与分类、分析与综合等多种方法,初步形成研究思路;2)理论研究阶段。在文献复习的基础上,界定重大疾病内涵,概述重大疾病保险相关理论,研究我国新型农村合作医疗制度现状,分析开展新型农村合作医疗重大疾病医疗保险工作的必要性;3)模式构建阶段。利用实证研究法和专家咨询法,以山东省新型农村合作医疗工作为基础,探讨建立山东省新型农村合作医疗重大疾病医疗保险运行模式的可行性,并初步构建山东省新型农村合作医疗重大疾病医疗保险运行模式;4)分析测算中,对相关数据的处理,采用了描述性统计分析、比较分析和多元统计分析法等。
     主要结果:
     1)2007-2011年5年间,山东省参合农民住院总费用平均增长率高达33.27%,人均费用平均增长率为30.00%,次均费用增长率为13.30%。2)2011年山东省参合农民住院费用平均个人自付比例为50.93%,住院费用越高,个人自付比例越大,在住院费用为8000元以上的参合农民中,个人自付比例为61.92%,在住院费用中个人自付部分达到8000元以上的参合农民中,个人自付比例为65.24%。3)共进行了2轮咨询,咨询专家22人,其中,卫生管理与新型农村合作医疗专家10人,临床专家6人,保险行业专家6人。形成了山东省新型农村合作医疗重大疾病医疗保险采取政府向商业保险机构购买医疗保险的方式运作的一致意见。4)山东省重大疾病医疗保险运行模式分三步走,分别为模式初级阶段、模式高级阶段和理想模式预期。初级阶段自2013年1月1日启动实施,人均筹资15元,重点保障20类重大疾病。高级阶段在2014年度实施,人均筹资35元,重点保障40类重大疾病。2015年进入理想模式,人均筹资60元,保障山东省参合农民所有大病大额医疗费用。5)建立新型农村合作医疗重大疾病医疗保险运行模式后,参合农民个人医药负担将显著减轻。费用超过10万元时,重大疾病患者实际报销比将达到85%以上,医疗费用越大,实际报销比例越高。当过渡到覆盖大病大额医疗费用后,山东省所有住院医疗费用达到1万元以上的参合居民,均可得到不低于90%的补偿。
     结论与建议:
     1)在我国大部分地区,新型农村合作医疗制度对重大疾病的保障作用还比较有限。2)重大疾病影响较大,有必要建立新型农村合作医疗重大疾病医疗保险运行模式,山东省具备建立基础和条件。3)较成功地构建了山东省新型农村合作医疗重大疾病医疗保险运行模式,并制定了“三步走”策略。4)建立新型农村合作医疗重大疾病医疗保险运行模式后,参合农民个人医药负担将显著减轻。模式建立初期,会激发重大疾病就医需求,随着工作推进,需求将逐步饱和,重大疾病医疗保险制度与重大疾病需求将达到良性发展状态,新型农村合作医疗制度也将随之不断巩固发展。5)根据研究结果,提出以下建议供参考:①科学筛选补偿病种,保障范围应逐步扩展;②进—步完善招标采购机制,保障药品和耗材供给;③合理确定合规医疗费用;④推进新型农村合作医疗支付方式改革,有效控制医疗费用过快增长。
Background:
     The New Cooperative Medical Scheme (NCMS) was a vigorous exploration to improve the health and medical insurance of peasants by Chinese government. In recent years, with the aging of the population and the changing of disease spectrum, the major diseases damaged the health and social development seriously, especially in rural areas. But the effect of insurance against catastrophic health expenditure was poor by the NCMS because of its low funding level. From2009, series reforms were implemented by Chinese government in health system, and the governments increased the subsidy for NCMS. With the funding level improved, it was necessary to study the working mode of insurance against major diseases by NCMS, which was beneficial to the peasants, NCMS and health reform.
     Objectives:
     This study aimed to establish a working mode of insurance against major diseases by NCMS in Shandong. The goal could be divided into5parts, included to study the conception of the major diseases, to study the related knowledge of insurance, to study the status of the NCMS in China, to analyze the necessity and feasibility for establishing a working mode of insurance against major diseases by NCMS, and to establish a working mode of insurance against major diseases by NCMS in Shandong.
     Methods:
     Based on the different objectives and different study contents, different methods were adopted, such as literature review, the Delphi Survey Method, empirical study and descriptive statistical analysis.
     Main Results:
     Ⅰ. From2007to2011, the growth rate of hospitalization expenses of the participants of the NCMS in Shandong was33.27%, the growth rate of the per capita costs was30.00%, and the growth rate of the average hospitalization expenses was13.30%.
     Ⅱ. In2011, the proportion of individual pays for hospitalization was50.98%in Shandong. And the proportion improved with the increasing of the hospitalization expenses. When the expenses were8000yuan or more, the mean proportion was61.92%, and when the individual pays were8000yuan or more, the mean proportion was65.24%.
     Ⅲ.22experts were selected and2surveys were conducted. The number of the NCMS experts, clinical experts and insurance experts were10,6and6respectively. The experts reached a consensus that the government should purchase insurance to commercial insurance agencies against major diseases in Shandong.
     Ⅳ. The working mode of insurance against major diseases by NCMS in Shandong was divided into3steps. In2013, the funding level was15yuan per capita, which insuring for20kinds of major diseases, in2014, the funding level was35yuan per capita, which insuring for40kinds of major diseases, and from2015, the funding level was60yuan per capita, which insuring against all the catastrophic health expenditures in participants of the NCMS in Shandong.
     Ⅴ. As the establishing of the working mode of insurance against major diseases by NCMS in Shandong, the compensation ratio of expenses for hospitalization of major diseases would be85%to90%, and the individual pays would be significantly reduced.
     Conclusions and Suggestions:
     Ⅰ.In most areas of China, the effect of insurance against catastrophic health expenditure was poor by the NCMS.
     Ⅱ.The major diseases'damage was so much and it should be pay more attention to establish a working mode of insurance against major diseases within NCMS. Trying to establish a working mode in Shandong was a good choice.
     Ⅲ.A working mode of insurance against major diseases within NCMS was established successfully in Shandong, which was divided into3steps.
     Ⅳ. As the establishing of the working mode of insurance against major diseases by NCMS in Shandong, the individual pays for hospitalization of major diseases would be significantly reduced. At the initial stage, the medical needs would be excited sharply, but the needs would gradually reach the state of saturation, so the future prospects of the working mode of insurance against major diseases would be better and better, and the NCMS would get a better development too.
     Ⅴ. Suggestions were put forward as follows:i) Select the insured diseases more scientifically and escalate the coverage, ⅱ) Take more measures to guarantee the supply of drugs and consumables for major diseases, ⅲ) Define the pay scope more scientifically, ⅳ) Implement the payment reform vigorously to contain the rise of the health expenditure.
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