济南市三县慢性病患者就医行为与疾病经济负担研究
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摘要
随着社会进步及人们生活水平的提高,疾病谱也在逐渐发生变化,疾病防治重点由传染病转移到慢性病和急性损伤方面。慢性病对社会产生了巨大的影响：2005年全国有7,471,000人死于慢性疾病,2006年卫生部公布的城乡居民的主要死亡原因为恶性肿瘤,据30个城市和78个农村县死亡原因统计恶性肿瘤的死亡率比2005年相比上升了18.6个百分点,以上数据说明一个问题,慢性病在居民整体健康水平中占据的地位越来越重要。为了减少农民的“因病致贫,因病返贫”的现象,2002年10月,全国农村卫生工作会议召开,要求各地区、各有关部门认真学习贯彻党的十六大精神和《中共中央、国务院关于进一步加强农村卫生工作的决定》(以下简称《决定》),决定中明确指出：“各级政府要积极组织引导农民建立以大病统筹为主的新型农村合作医疗制度,重点解决农民因患传染病、地方病等大病而出现的因病致贫、返贫问题。”目前,新型农村合作医疗制度是农村地区主要的医疗保障形式。新型农村合作医疗制度,从2003年试点,到现在运行了近五年的时间,目前已覆盖全国所有含农业人口的县(市、区),参合人数达8.33亿,其是否能减轻慢性病患者疾病经济负担,是否影响慢性病患者就诊机构的选择?
研究目的：通过分析2008年济南市三县居民慢性病的患病情况、医疗费用及影响因素,探讨慢性病流行现状及医疗保障程度,进一步分担疾病负担重者的经济风险,提高他们的医疗服务可及性和利用公平性,为农村合作医疗慢性病管理政策的制定提供依据。
研究方法：本研究采用多阶段抽样的方法,根据经济发展水平,抽取济南市的三个县区进行调查和分析,包括经济相对发达的章丘市,经济中等发达的长清区和经济相对欠发达的平阴县。从每个县区抽取的6个乡镇中随机抽取3个乡镇,每个乡镇抽取6个村,然后每个村农户中随机抽取约20户。最后本研究的样本量为3701例,分析三县居民的慢性病的患病情况、医疗费用及影响因素。分析方法主要为描述性分析、单因素分析以及多元线性回归分析。
研究的主要结果：(1)患病率情况：女性患病率稍高于男性患病率；随年龄的增加患病率增加的疾病有：高血压、冠心病、腰椎间盘突出、糖尿病、脑血栓、心脏病(除冠心病)(除冠心病),但不同的疾病的患病率上升明显的年龄组不同,40岁以后为颈椎病、关节炎高发年龄段；经济收入高的组患病率高于经济收入低的组。影响慢性病患病率的因素有地区、性别、年龄、婚姻状况、受教育程度、职业、自评经济收入。(2)卫生服务利用：农村慢性病患者的住院机构主要为村卫生室(28.5%),其次是县级医疗机构(27.6%)。(3)慢性病的疾病经济负担：仅45.3%的患者能完全承担年医疗费用负担,而住院费用在4000元以内占58.6%。
结论：(1)不同经济收入组的卫生服务利用的机构也是不同的,经济因素是农村居民卫生服务机构选择的主要影响因素。(2)新型农村合作医疗对农村慢性病患者的疾病经济负担的影响不大,但是,合作医疗引导农村居民选择就医机构,首先在基层医疗机构就诊，这就降低了疾病经济负担。(3)减轻慢性病疾病经济负担的根本途径是新型农村合作医疗增加对慢性病患者的补偿,并对慢性病患者进行慢性病管理。
建议：(1)村卫生室和乡镇卫生院是农村居民主要利用的医疗服务机构,出台相应的政策并采取有力措施改善这两级医疗机构的医疗环境、医务人员素质,提高医疗诊断水平。(2)新型农村合作医疗制度能够影响参合农村居民的就诊流向,因此加强并改善这一作用.保证参合农村居民的小病、常见病都消化在基层医疗机构。(3)新型农村合作医疗制度的筹资水平决定了其解决农村居民因病致贫和因病返贫的能力较弱,在客观上需要这一制度与医疗救助制度相衔接,这需要出台相关政策保证有效实施。(4)出台相关政策或制度,促进慢性病管理制度的建立,从而对慢性病进行全程监控,降低慢性病进展所带来的更沉重的家庭和社会疾病经济负担。
With the advancement of society and the improvement of people's living standards, diseases gradually transferred the focus from contagious disease prevention and control to the treatment of chronic disease and acute injury. Chronic diseases exercise great influence on the society:In 2005,7,471,000 people nationwide died from chronic diseases. In 2006, the Ministry of Health declared malignant tumour as a major cause of death for urban and rural residents, and the death rate due to malignant tumour increased by 18.6 percent compared with 2005 for 30 urban cities and 78 rural areas.
The above statistics show that chronic diseases played a more significant role in health of all the residents. To reduce the peasants'phenomenon of "illnesses cause by poverty and illnesses lead to poverty", in October 2002, the National Rural Health Conference required all districts and departments to learn and implement the spirit of Sixteenth CPC National Congress and The CPC Central Commitwe and the State Council On Further S(?)engthening the Work of Rural Health Decisions (hereinafter referred to as the Decisions. the decision clearly states: Governments at all levels should actively guide the farmers to establish new rural cooperative medical system; mainly focus on peasants' poverty problems caused by major illnesses such as contagious diseases, endemic diseases. At present, the new rural cooperative medical system in rural areas is the main form of medical insurance. The new rural cooperative medical system has been operated for nearly five years since the demonstration pilot in 2003, and has covered all the agricultural population of the rural counties, cities, districts, the number of participants reaching 833 million. Whether it can relieve the burden of the patients of chronic diseases and whether it can affect the choosing of the medical institutions for the patients with chronic diseases remains to be seen.
Objective:By analyzing the situation of chronic disease patients, the cost of medical treatment and the affecting factors in three countryside of Shandong Province in 2008, the research aims to discuss the chronic disease situation and the level of medical insurance, and to further share the severe economic burden of the patients and to improve their health Service availability and strengthen the equality of the use of medical service, and to provide the basis for the policy formulation of rural cooperative medical management of chronic diseases.
Methods:This study used a stratified sampling method. According to the economic development level, three countryside of Jinan City were selected for investigation and analysis, including relatively developed zhangqiu, moderately developed changing and relatively undeveloped PingYin. Twenty rural households were selected from thirty families from six random villages from three random rural towns from these three cities. Finally, the study's samples amount to 3701 to analyze the prevalence of chronic diseases, medical costs and affecting factors of three counties'residents. The analysis methods are mainly descriptive analysis, univariate analysis and multiple linear regression analysis.
The main results:(1)prevalence rate; Female prevalence rate is slightly higher than male prevalence; The diseases which are prevalence increased as age increase are as follows:hypertension, coronary heart disease, lumbar disc, diabetes, cerebral thrombosis, heart disease. However, the prevalence of different diseases increased significantly in different age groups. There is a high increase of cervical spondylosis, arthritis after 40 years old. The backache and leg hurts prefer the people who are more than 50 years old. The prevalence rate of high income group is higher than low income group. Factors that affect the prevalence of chronic diseases are area, gender, age, marital status, education level, career and self-evaluation economic income. (2)Health services utilization:Hospital patients with chronic diseases in rural areas go mainly to the village health organizations (28.5%), and to county-level medical institutions(27.6%). (3)Economic burden of chronic disease patients:Only 45.3% of the patients were able to fully assume the burden of medical costs, but the hospitalization costs of less than 4000 RMB accounted for 58.6%
Conclusion:(1)Different income groups use different health service organizations and the economic situation are the main factors for rural residents to choose health service organizations. (2)The new rural cooperative medical care is of little effect on economic burden of chronic patients; however, the rural cooperative medical care guides residents to choose medical institutions and the first choice goes to primary health care institutions, which reduces the economic burden of patients. (3)The fundamental way to reduce the economic burden of patients in chronic disease is to for the new rural cooperative medical increase the compensation to the chronic patients. and take charge of patients who are in chronic diseases.
Suggestions:(1)Village clinic and rural hospitals are the main medical services departments for the rural residents, so there should be corresponding policies and measures to improve the two departments'medical environment, personnel quality, and the level of medical diagnosis.(2) The new rural cooperative medical care system can affect the doctor-choosing flow of rural residents, so it is necessary to strengthen and improve the effect, to ensure the common ailment to disappear with the help of basic medical department.(3) The financing level of the new rural cooperative medical care system determines the weak ability of solving rural residents poverty from disease, so this system needs o be connected with medical assistance syst m and require effective implementation of corresponding policies. (4) Issue relevant policy or system to promote the establishment of chronic management system to monitor the whole being of chronic patients nd reduce the family economic burdens caused by chronic disease.
研究目的：通过分析2008年济南市三县居民慢性病的患病情况、医疗费用及影响因素,探讨慢性病流行现状及医疗保障程度,进一步分担疾病负担重者的经济风险,提高他们的医疗服务可及性和利用公平性,为农村合作医疗慢性病管理政策的制定提供依据。
研究方法：本研究采用多阶段抽样的方法,根据经济发展水平,抽取济南市的三个县区进行调查和分析,包括经济相对发达的章丘市,经济中等发达的长清区和经济相对欠发达的平阴县。从每个县区抽取的6个乡镇中随机抽取3个乡镇,每个乡镇抽取6个村,然后每个村农户中随机抽取约20户。最后本研究的样本量为3701例,分析三县居民的慢性病的患病情况、医疗费用及影响因素。分析方法主要为描述性分析、单因素分析以及多元线性回归分析。
研究的主要结果：(1)患病率情况：女性患病率稍高于男性患病率；随年龄的增加患病率增加的疾病有：高血压、冠心病、腰椎间盘突出、糖尿病、脑血栓、心脏病(除冠心病)(除冠心病),但不同的疾病的患病率上升明显的年龄组不同,40岁以后为颈椎病、关节炎高发年龄段；经济收入高的组患病率高于经济收入低的组。影响慢性病患病率的因素有地区、性别、年龄、婚姻状况、受教育程度、职业、自评经济收入。(2)卫生服务利用：农村慢性病患者的住院机构主要为村卫生室(28.5%),其次是县级医疗机构(27.6%)。(3)慢性病的疾病经济负担：仅45.3%的患者能完全承担年医疗费用负担,而住院费用在4000元以内占58.6%。
结论：(1)不同经济收入组的卫生服务利用的机构也是不同的,经济因素是农村居民卫生服务机构选择的主要影响因素。(2)新型农村合作医疗对农村慢性病患者的疾病经济负担的影响不大,但是,合作医疗引导农村居民选择就医机构,首先在基层医疗机构就诊，这就降低了疾病经济负担。(3)减轻慢性病疾病经济负担的根本途径是新型农村合作医疗增加对慢性病患者的补偿,并对慢性病患者进行慢性病管理。
建议：(1)村卫生室和乡镇卫生院是农村居民主要利用的医疗服务机构,出台相应的政策并采取有力措施改善这两级医疗机构的医疗环境、医务人员素质,提高医疗诊断水平。(2)新型农村合作医疗制度能够影响参合农村居民的就诊流向,因此加强并改善这一作用.保证参合农村居民的小病、常见病都消化在基层医疗机构。(3)新型农村合作医疗制度的筹资水平决定了其解决农村居民因病致贫和因病返贫的能力较弱,在客观上需要这一制度与医疗救助制度相衔接,这需要出台相关政策保证有效实施。(4)出台相关政策或制度,促进慢性病管理制度的建立,从而对慢性病进行全程监控,降低慢性病进展所带来的更沉重的家庭和社会疾病经济负担。
With the advancement of society and the improvement of people's living standards, diseases gradually transferred the focus from contagious disease prevention and control to the treatment of chronic disease and acute injury. Chronic diseases exercise great influence on the society:In 2005,7,471,000 people nationwide died from chronic diseases. In 2006, the Ministry of Health declared malignant tumour as a major cause of death for urban and rural residents, and the death rate due to malignant tumour increased by 18.6 percent compared with 2005 for 30 urban cities and 78 rural areas.
The above statistics show that chronic diseases played a more significant role in health of all the residents. To reduce the peasants'phenomenon of "illnesses cause by poverty and illnesses lead to poverty", in October 2002, the National Rural Health Conference required all districts and departments to learn and implement the spirit of Sixteenth CPC National Congress and The CPC Central Commitwe and the State Council On Further S(?)engthening the Work of Rural Health Decisions (hereinafter referred to as the Decisions. the decision clearly states: Governments at all levels should actively guide the farmers to establish new rural cooperative medical system; mainly focus on peasants' poverty problems caused by major illnesses such as contagious diseases, endemic diseases. At present, the new rural cooperative medical system in rural areas is the main form of medical insurance. The new rural cooperative medical system has been operated for nearly five years since the demonstration pilot in 2003, and has covered all the agricultural population of the rural counties, cities, districts, the number of participants reaching 833 million. Whether it can relieve the burden of the patients of chronic diseases and whether it can affect the choosing of the medical institutions for the patients with chronic diseases remains to be seen.
Objective:By analyzing the situation of chronic disease patients, the cost of medical treatment and the affecting factors in three countryside of Shandong Province in 2008, the research aims to discuss the chronic disease situation and the level of medical insurance, and to further share the severe economic burden of the patients and to improve their health Service availability and strengthen the equality of the use of medical service, and to provide the basis for the policy formulation of rural cooperative medical management of chronic diseases.
Methods:This study used a stratified sampling method. According to the economic development level, three countryside of Jinan City were selected for investigation and analysis, including relatively developed zhangqiu, moderately developed changing and relatively undeveloped PingYin. Twenty rural households were selected from thirty families from six random villages from three random rural towns from these three cities. Finally, the study's samples amount to 3701 to analyze the prevalence of chronic diseases, medical costs and affecting factors of three counties'residents. The analysis methods are mainly descriptive analysis, univariate analysis and multiple linear regression analysis.
The main results:(1)prevalence rate; Female prevalence rate is slightly higher than male prevalence; The diseases which are prevalence increased as age increase are as follows:hypertension, coronary heart disease, lumbar disc, diabetes, cerebral thrombosis, heart disease. However, the prevalence of different diseases increased significantly in different age groups. There is a high increase of cervical spondylosis, arthritis after 40 years old. The backache and leg hurts prefer the people who are more than 50 years old. The prevalence rate of high income group is higher than low income group. Factors that affect the prevalence of chronic diseases are area, gender, age, marital status, education level, career and self-evaluation economic income. (2)Health services utilization:Hospital patients with chronic diseases in rural areas go mainly to the village health organizations (28.5%), and to county-level medical institutions(27.6%). (3)Economic burden of chronic disease patients:Only 45.3% of the patients were able to fully assume the burden of medical costs, but the hospitalization costs of less than 4000 RMB accounted for 58.6%
Conclusion:(1)Different income groups use different health service organizations and the economic situation are the main factors for rural residents to choose health service organizations. (2)The new rural cooperative medical care is of little effect on economic burden of chronic patients; however, the rural cooperative medical care guides residents to choose medical institutions and the first choice goes to primary health care institutions, which reduces the economic burden of patients. (3)The fundamental way to reduce the economic burden of patients in chronic disease is to for the new rural cooperative medical increase the compensation to the chronic patients. and take charge of patients who are in chronic diseases.
Suggestions:(1)Village clinic and rural hospitals are the main medical services departments for the rural residents, so there should be corresponding policies and measures to improve the two departments'medical environment, personnel quality, and the level of medical diagnosis.(2) The new rural cooperative medical care system can affect the doctor-choosing flow of rural residents, so it is necessary to strengthen and improve the effect, to ensure the common ailment to disappear with the help of basic medical department.(3) The financing level of the new rural cooperative medical care system determines the weak ability of solving rural residents poverty from disease, so this system needs o be connected with medical assistance syst m and require effective implementation of corresponding policies. (4) Issue relevant policy or system to promote the establishment of chronic management system to monitor the whole being of chronic patients nd reduce the family economic burdens caused by chronic disease.
引文
[1]段纪俊,施侣元.慢性病流行状况、趋势与误区.国外医学一社会医学分册,2005年,22(4)：177.179.
[2]百度网.http://tjsj.baidu.com.2008年3月17日.
[3]卫生部统计信息中心中国卫生服务调查研究.中国协和医科大学出版社：ISBN7-81072.593.9/R.587:北京.2004.
[4]中华人民共和国卫生部.www.moh.gov.cn.2008年3月17日。
[5]绵阳市疾控.http://www.mycdc.cn/Article/ ShowArticle.Asp/ArticlelD=30.2007年7月16日.
[6]新闻中心.http://news.tom.com/2007.11.12/11/355378.html.2007年11月25日.
[7]许可,龚向光,应晓华.对城市贫困人12医疗救助的理论探讨.中国卫生经济,1999,13(5)：30-32.
[8]尹冬梅,胡善联,程晓明等.中国贫困农村地区卫生服务公平性研究.中国卫生经济,1999,18(3)：7-10.
[9]黄金龙等.澳门社区卫生服务模式及体会.中华全科医师杂志,2003,11(2)：374-375.
[10]张震巍等.中国糖尿病直接卫生费用研究.中国卫生资源,2007,10(3)：162—164.
[11]汤质如等.安徽省肥西县新型农村合作医疗研究(二).中国卫生经济,2004,23(12)：15.16.
[12]袁兆康等.新型农村合作医疗制度对农民医疗费用的影响研究.中国卫生事业管理,2005,25(5)：11-14.
[13]李贝,毛宗福,李建平,等.湖北省居民住院费用影响因素分析[J].中国卫生事业管理,2005(8)：483—485.
[14]王方,王正洪,张曙光.新农合患者住院医疗费用影响因素分析[J].华南国防医学杂志,2009,23(3)：81-82.
[15]冯兆田,徐凌中,宋月雁.新型农村合作医疗病人住院流向分析及其影响因素研究[J].现代医院管理.2007,5(3)：74—76.
[2]百度网.http://tjsj.baidu.com.2008年3月17日.
[3]卫生部统计信息中心中国卫生服务调查研究.中国协和医科大学出版社：ISBN7-81072.593.9/R.587:北京.2004.
[4]中华人民共和国卫生部.www.moh.gov.cn.2008年3月17日。
[5]绵阳市疾控.http://www.mycdc.cn/Article/ ShowArticle.Asp/ArticlelD=30.2007年7月16日.
[6]新闻中心.http://news.tom.com/2007.11.12/11/355378.html.2007年11月25日.
[7]许可,龚向光,应晓华.对城市贫困人12医疗救助的理论探讨.中国卫生经济,1999,13(5)：30-32.
[8]尹冬梅,胡善联,程晓明等.中国贫困农村地区卫生服务公平性研究.中国卫生经济,1999,18(3)：7-10.
[9]黄金龙等.澳门社区卫生服务模式及体会.中华全科医师杂志,2003,11(2)：374-375.
[10]张震巍等.中国糖尿病直接卫生费用研究.中国卫生资源,2007,10(3)：162—164.
[11]汤质如等.安徽省肥西县新型农村合作医疗研究(二).中国卫生经济,2004,23(12)：15.16.
[12]袁兆康等.新型农村合作医疗制度对农民医疗费用的影响研究.中国卫生事业管理,2005,25(5)：11-14.
[13]李贝,毛宗福,李建平,等.湖北省居民住院费用影响因素分析[J].中国卫生事业管理,2005(8)：483—485.
[14]王方,王正洪,张曙光.新农合患者住院医疗费用影响因素分析[J].华南国防医学杂志,2009,23(3)：81-82.
[15]冯兆田,徐凌中,宋月雁.新型农村合作医疗病人住院流向分析及其影响因素研究[J].现代医院管理.2007,5(3)：74—76.