我国全民医保推进下城镇地区卫生筹资的效应分析
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摘要
一、研究背景
WHO执行委员会于2005年提出了“全民覆盖”概念,也称作为“全民健康保险覆盖”或“全民医保”,即每个国家通过建立良好筹资的保障体系,保证所有公民能够在可负担的水平上获得必要的卫生服务。2010年,WHO进一步为“全民医保”的实现制定了操作指南,对任何一个国家来说,无论其发展水平,“全民医保”都应是其政策制定的优先目标。“全民医保”的实施需要解答政府、社会、个人应当怎样筹集资金来支付所发生的卫生服务,从而保证个人能够负担得起所需要的服务。由此可见,“全民医保”的基础是建立良好的卫生筹资体系。
卫生筹资体系通过税收、社会医疗保险等形式筹集社会公共资源,在不同健康状况、不同支付能力的人群中进行分摊,并利用这些筹集的资源向卫生服务提供方购买服务。卫生筹资的目标之一是使不同人群间经济负担趋向于公平。筹资公平性可分为水平公平和垂直公平：水平公平是指具有相同支付能力的人应支付相同的费用；垂直公平是指具有不同支付能力的人支付的卫生费用不同,支付能力高的人应该支付更多的费用。在全民医保实施下采取合理的筹资方式,能够有效地起到保障个人或家庭财务风险的作用,使人们在有卫生服务需求时能及时获得服务,最终促进人群的总体健康水平,达到“全民健康”的目的。
新中国的医疗保障制度建立至今已有60余年,回顾其历史,从建国后的公费、劳保医疗制度、农村合作医疗制度到后来的城镇职工/居民医疗保险制度、新型农村合作医疗制度,我国的医保制度经历了起起落落的几个阶段。在全民医保的开展之前,我国医保覆盖面较低,看病贵、看病难问题突出,个人现金支付的比例不断上升,成为卫生筹资的主要问题。WH02000年的报告表明,当时我国的卫生筹资公平性在191个成员国中排在188位,卫生筹资公平性非常不理想。而在2009年的新医改之后,我国开始了“全民医保”的全面推进。虽然在制度建设、筹资水平、保障水平等问题上还存在诸多挑战,但“全民医保”的基本实现已经成为现实。
21世纪初我国卫生筹资公平性的下降引起了国内许多学者的重视,涌现了许多以卫生筹资及其公平性作为重点内容的研究,在理论上及分析评价方法上都取得了较大进展。2003年之后,随着新农合的改革以及城镇职工基本医疗保险的不断推进,我国卫生筹资的公平性有了明显改善。关于新农合的研究表明,新农合改善了各个收入层次人群的卫生服务利用,降低了农民的灾难性卫生支出风险。而针对我国城镇地区人群的卫生筹资研究主要反映的是城镇居民医保实施前的情况,现有研究缺乏对新形势下,有其是新医改实施后城镇地区卫生筹资的评价。并且现有研究利用专门针对城镇地区人群卫生服务利用及筹资状况的数据较少。因此,评估新医改启动后“全民医保”基本实现的前提下,我国城镇地区卫生筹资及公平性现状以及评价城镇地区医保改革带来的影响是非常重要的。
二、研究目的
本研究以我国推进“全民医保”过程中实行城镇居民基本医疗保险改革的典型试点城市为样本,结合卫生改革的筹资理论,以城镇居民家庭为视角,通过对居民卫生服务利用以及家庭经济状况、生活支出的考察,评估和研究我国城镇地区在基本实现“全民医保”后,当前卫生筹资体系下城镇人群卫生服务利用与卫生筹资公平性及财务风险保护情况的变化,为城镇地区基本医疗保险制度的发展和完善提供现实参考。具体目标包括：
1.基于卫生改革的筹资理论,描述分析我国“全民医保”制度在城镇地区的发展、挑战和存在的问题,以及全民医保制度的筹资体系现状；
2.实证分析全民医保背景下城镇人群的卫生服务利用及公平性现状；
3.实证分析全民医保背景下城镇人群的卫生筹资及公平性现状；
4.实证分析全民医保背景下城镇人群的财务风险保护现状；
5.实证分析全民医保背景下城镇人群的健康水平及促进现状；
6.针对分析结果提出改善我国现有城镇医保制度筹资方式的建议。
三、研究方法
(一)卫生筹资体系的效应分析框架
本研究将卫生系统强化的监测和评价框架与卫生改革发展框架相结合,同时舍去原有框架中针对供方的评价内容,来评价和分析我国全民医保推进下卫生筹资体系的效应。利用家庭卫生服务调查的实证数据,对“全民医保推进”——“城镇居民卫生服务利用、筹资公平性评价”——“城镇居民健康状况、财务风险保护的影响”这一结果链进行综合考察和评价。
(二)资料来源
1.抽样调查
本研究根据中国各省市不同的地理位置和经济发展状况,选择第一批居民医保试点城市中的西部和东部城市各一个作为研究对象,并根据项目开展、资料获取的可行性,在西部试点城市中选择陕西省宝鸡市作为样本城市,在东部试点城市中选择浙江省杭州市作为样本城市。采取多阶段分层随机抽样的方法,在两个城市中随机选取一定数量的居民家庭,并以家庭中全体城镇户籍居民为调查对象(常住非户籍居民不纳入调查),作为我国城镇地区居民的样本代表,分析其卫生服务利用及筹资现状。本研究通过连续三年(2009、2010、2011)的入户调查,对两个样本城市家庭成员的相关卫生服务利用及筹资数据进行连续性收集和监测。同时调查根据第一轮调查进行回访的原则,考察同一家庭在三年内的变化情况。
2.二手资料收集
包括查阅国内外全民医保及卫生筹资研究,回顾中央政府、宝鸡市和杭州市政府关于城镇地区医疗保险制度实施、推进等重要政策文件,以及查找世界卫生组织网站、国家卫生部、人力资源与社会保障部、样本市卫生局、劳动及社会保障局等主要政府部门数据统计结果。
(三)分析方法
1.文献回顾及归纳
对收集的文献及政策文件等二手资料进行归纳和总结,分析我国医保体系的发展过程及“全民医保”实施的必然性,以及卫生筹资系统的现状。
2.卫生服务利用及卫生筹资的公平性分析
通过比率比较、Gini系数、集中指数、卫生服务利用的标准化及水平不公平指数、Kakwani指数等对样本居民的卫生服务利用和卫生筹资公平性做实证分析。
3.财务风险保护分析
测算灾难性卫生支出发生率,分析家庭遭遇灾难性卫生支出打击的严重程度等,反映现有医保及卫生筹资系统下人群受财务风险保护的强度。
4.人群健康状况分析
以欧洲五维健康量表(EQ-5D)进行测量,描述15岁及以上居民的健康相关生命质量,考察居民健康水平的变化。
5.统计分析工具
家庭入户调查资料以Epidata3.1进行录入,并导入SPSS18.0进行统计分析。
四、研究结果
(一)新医改实施对我国全民医保建设和卫生筹资系统完善起到了重要作用
在新医改实施前,我国的卫生系统和卫生筹资上存在着个人支出负担较重、医疗保险保障不足、资源配置和利用效率较低、地区及制度间卫生筹资不公平的问题。随着2009年开始的新医改实施,我国首次明确了“全民医保”的目标,在新医改实施下我国卫生筹资体系也发生了重要的改变,从筹资来源和筹资形式上来说,新医改下卫生筹资的重要目标是放大政府财政筹资和社会保险筹资的功能,其目的是要降低个
人现金支付的比例,符合了全民医保卫生筹资体系建设的要求,值得称道。(二)我国已建立基本的全民医保体系且覆盖面较广、制度建立较完善
本研究以杭州和宝鸡作为东部城市中西部城市的样本代表,调查显示两城市的基本医保覆盖面已达到95%以上,样本城市的城镇基本医保的覆盖情况非常良好,从覆盖面上来说基本达到了全民医保的要求,显现了新医改后全民医保取得的巨大成就。从两个城市的医保制度运行情况、筹资方式及保障待遇上来看,目前的城镇基本医保制度能够针对不同的人群设计不同的筹资及保障方式。两个城市作为城镇居民医保改革试点的第一批城市,居民医保的政策也在这几年间不断的调整,筹资水平和保障待遇逐步提高,表现了政府尽最大可能来减轻居民的医疗经济负担的决心。
(三)不同地区间、不同医保制度间的卫生筹资及保障待遇差异明显
我国目前不同地区的医保采取属地化管理,各地社会经济发展水平的差异使不同地区间的筹资及保障待遇差距明显。保障待遇方面杭州两类城镇基本保险的门诊保障水平都较高,宝鸡的城镇基本医保则主要是“保大病”,门诊方面的补偿待遇较低。此外,居民医保的筹资主要由政府财政投入,筹资水平远不如职工医保,因而导致两类医保人群在保障待遇上的差距。无论从地区差异还是制度差异来说,我国目前的全民医保还仅处于最基本的阶段,不同人群的差距容易造成不公平的现象。
(四)不同地区及医保参保人群间的门诊及住院服务利用存在差异
由于杭州和宝鸡在卫生筹资及医保保障制度上的差异,使两个城市居民的门诊和住院服务利用产生了较大的区别。杭州的卫生筹资水平较高,对门诊的保障力度较大,因而杭州的门诊服务利用率较高。而宝鸡在门诊方面的筹资水平较低,保障水平也较低,制约了宝鸡居民门诊服务的使用。但住院率上则呈相反的情况,宝鸡年住院率反而高于杭州,反映出宝鸡居民由于住院保障力度相对门诊高,可能发生多利用住院服务来治疗原本能够通过门诊治疗的疾病,导致了住院率的上升。本研究利用卫生服务标准化的方法计算了门诊和住院次数的集中指数和HIwv指标,结果反映近三年来两个样本城市门诊服务利用在不同经济水平人群中的公平性较为良好,但住院服务利用上两个城市都存在不公平的现象,经济水平高的人群能更多的使用住院服务。目前的全民医保体系和卫生筹资水平对住院服务的使用并没有起到根本性的改善。
(五)城镇地区医疗费用个人承担比例仍较高且存在地区和制度间的差异
数据结果显示了由东西部城市社会经济水平的差异所导致的医疗费用水平上的差距,这一差距在住院费用上体现的更加明显。从医疗费用个人承担比例上看,杭州的门诊保障待遇水平较高,个人需要承担的自付费用比例仅在35%左右；宝鸡的门诊补偿待遇则较低,尤其是居民医保基本上没有实质性的医保报销,基本上全部依靠个人自付来承担。住院保障上两个城市之间的差异较小,杭州个人承担的比例在40%左右,宝鸡个人承担比例在45%左右。从个人承担比例上看我国全民医保就保障力度而言仍然处于非常基础的水平。而比较两类城镇基本医保制度,结果显示职工医保无论是门诊还是住院其个人承担的比例都比居民医保要低。不同地区和医保制度间的差距,意味着城镇地区卫生筹资存在水平不公平现象。
(六)城镇地区卫生筹资的公平性及累进性较差
通过各类卫生支出集中指数、各类经济能力衡量标准的Gini系数以及Kakwani指数等指标来评价目前我国城镇地区卫生筹资的公平性,结果显示新医改实施后全民医保体系下我国目前城镇地区的卫生筹资仍然属于累退性。各类Kakwani指数都呈负值说明卫生筹资在低经济水平家庭中的比重要高于其所对应的经济能力的比重,对于低经济水平家庭来说卫生筹资的负担更重。通过再分配效应分析,结果表明筹资后的经济水平分布比筹资前的不公平程度加剧,卫生筹资的累退性带来的不公平也容易引起灾难性卫生支出的发生,从而影响人群的生活水平和健康状况。
(七)城镇地区家庭灾难性卫生支出发生率仍较高
数据结果显示杭州的灾难性卫生支出发生率在11%左右,宝鸡的发生率为15%左右,这一结果表明目前我国家庭的现金卫生支出对家庭生活水平带来的负面影响较大,虽然全民医保的覆盖面较广,但通过卫生筹资并没有给家庭的财务风险带来较好的保障。灾难性卫生支出家庭的生活水平明显低于未发生灾难性卫生支出的家庭,其卫生支出占家庭消费支出的比例平均在60%,与界定标准40%的差距较大。是否发生灾难性卫生支出的集中指数显示了灾难性卫生支出的发生比较偏向于低经济水平的家庭,低水平家庭的财务风险保护状况较为不理想。
(八)城镇地区人群健康状况变化未显示明显的改善
利用EQ-5D量表对调查人群的健康相关生命质量进行评价,总体上EQ-5D的VAS得分和指数得分反映杭州和宝鸡城镇居民的平均健康水平尚处于良好的水平。考虑到本研究三年间采用回访的方式进行调查,可能受回访居民年龄增长带来的健康水平下降的影响,EQ-5D两类得分都显示了三年间略有降低的情况。现有结果说明新医改实施后的三年内,全民医保的覆盖并没有给城镇居民带来实质性的健康状况改善,居民主观上并未认为自己的健康水平有所提高。需要指出的是由于政策对于健康状况的改善效应有其滞后性,在新医改实施后的前三年短时期内,通过调查数据反映出的居民自我认知状况尚不能充分反映真实的健康状况改变,仍需要通过长期的监测来评价居民的健康状况改善。
五、政策建议
(一)加大政府投入和提高社会保险筹资水平,降低医疗费用个人承担比例新医改实施后的近3年政府已经投入8500亿元用于卫生事业发展,但从城镇地区居民的服务利用和卫生筹资变化上看,投入仍然没有根本改变居民卫生筹资的不公平状况。因此,政府的大力投入应当继续保持,不仅需要保证居民的参保,还需要进一步提高居民的医保保障待遇,进一步降低卫生筹资中个人承担的比例。
(二)在提高卫生筹资公平性的同时注重卫生筹资的配置和使用效率
在目前卫生筹资资源有限的情况下,政府应坚定不移的支持基层卫生机构的发展,支持公共卫生服务、基本卫生服务、基本药物的提供,同时探索供方支付方式改革、需方过度服务需求的控制等,通过与卫生筹资相关的各类配套政策的实施和管理,促进卫生筹资的效率,提高全民医保体系的保障力度和卫生筹资的公平性。
(三)推动城乡统筹和制度统筹,提升统筹层次,缩小区域性差异和制度性差异
不同城市间的区域差异和不同医保制度之间的差异是造成卫生筹资水平不公平的重要原因。政府应着重对中西部城市或其他社会经济水平较低的区域的财政投入,缩小不同区域间的保障水平差距；同时继续提高居民医保的保障水平,使其向职工医保的保障待遇靠拢,尤其针对居民医保门诊的保障应逐步提高补偿水平,缩小不同医保人群的保障待遇差距。
(四)在医保筹资中引入累进性的筹资机制
目前我国卫生筹资体系的累退性,一部分原因是医疗保障制度实施中并没有根据个人的经济水平采取不同的筹资比例,因此需要建立符合公平要求的医疗保障筹资机制,做到政策向低收入者和贫困人群倾斜。
(五)强化医疗救助作用,重点帮助灾难性卫生支出家庭
灾难性支出家庭对于卫生筹资公平性的影响非常大,降低灾难性支出家庭的比例可以明显改善家庭卫生筹资的公平性。目前我国的医疗救助制度已经发展相对较为成熟,通过对灾难性卫生支出的测算,可以更好的有针对性的发挥医疗救助制度对弱势人群的保障力度。此外,不仅要强化医疗救助的事后救助,还要建立医疗救助的事先救助,帮助面临高额医疗费用家庭接受所需要的医疗服务。
(六)树立全民医保和卫生筹资公平性理念,加强监测与评估
对于全民医保费用和服务保障维度的实现,不能只停留在关注医保政策范围内医疗费用报销比例和医疗费用实际报销比例,而是需要着眼于卫生筹资的整体,关注整个卫生筹资体系的筹资结构和筹资效应。因此需要建立对于我国卫生筹资体系的监测与分析机制,使其成为卫生系统绩效评估的重要组成部分。
Background
WHO Executive Committee proposed the concept of'Universal Coverage'in2005, also known as'Universal Health Insurance Coverage'or'Universal Health Coverage'. It refers to countries ensuring all citizens to obtain the necessary health services under an affordable level through the establishment of a good financed insurance system. In2010, WHO further developed an operation guide for achieving universal health coverage. For any country regardless of their development level, universal health coverage should be the priority objectives of its policy-making. The implementation of universal health coverage needs to answer the question that how to raise funds to pay for health services from government, society and individuals and to ensure individuals being able to afford those services. Thus, the basis of'universal coverage'is to establish a good health financing system.
A health financing system raises public resources through taxation, social health insurance and other forms, shares them in individuals with different health status and ability to pay, and uses these resources to purchase services from health service providers. One of the objectives of health financing is to make the economic burden between different groups of people tend to be fair. Equity in health financing can be divided into horizontal equity and vertical equity. Horizontal equity means those have same ability to pay should pay the same fees. Vertical equity means people with different ability to pay should bear different health costs. Adopting reasonable means of financing when implementing universal health coverage can effectively protect the financial risk so that people can use services timely when they have the health service needs, and ultimately promote the overall health of population and achieve the goal of'health for all'.
The medical insurance system in China has established for more than60years. Reviewing its history, the system has undergone several stages from public funded medical care, labor protection medical care, the rural cooperative medical system to the urban employees/residents basic medical insurance (UEBMI/URBMI), the new rural cooperative medical care system (NCMS). Before the promotion of universal health coverage, the low health insurance coverage in China and the increasing proportion of out-of-pocket (OOP) payments become the main problems in health financing. In2000, WHO report shows that China's equity in health financing ranked188in the191member states, which was far from ideal. After a new healthcare reform in2009, China began to comprehensively promote universal health coverage. Although there are still many challenges in the system construction, funding levels, protection levels and other issues, the basic achieving of universal health coverage has become a reality.
In the early21st century, the declining of equity in health financing aroused the attention of many domestic scholars. The emergence of researches focusing on health financing and equity had made great progresses both in theory and the analysis methods. After2003, the equity in health financing in China has been significantly improved as to the reform of the new rural cooperative medical care system and urban employees basic medical insurance. Studies on new rural cooperative medical care system showed that it improved health services utilization for people with different income levels and reduced farmers' catastrophic health expenditure (CHE) risk. Studies on health financing in China's urban areas reflected the situation prior to the implementation of urban residents basic medical insurance. There are few existing researches focusing on the new situation, especially after the implementation of the new healthcare reform. And less existing researches used data of health services utilization and the financing status specifically for urban areas. Therefore, it is important to assess the current situation of equity in health financing and the impact of insurance reform under the background of universal health coverage after the new healthcare reform in China's urban areas.
Objectives
This study chose the typical pilot cities implementing the urban residents basic medical insurance reform as samples. Combined with the theory of financing in health reform, we took the perspective of urban households and investigated the utilization of health services and family economic conditions. The objective was to assess the changes in utilization of health services, equity in health financing and the protection of financial risk of urban populations in the current health financing system after the basic achieving of universal health coverage. Policy suggestions would be provided to promote the development of the basic medical insurance system in urban areas.
Specific objectives include:
1. Based on the theory of financing in the health reform, describing and analyzing the development, challenges and existing problems of universal health coverage in China, as well as the current situation of health financing system;
2. Empirical Analysis on the current situation of utilization of health services and its equity in urban areas;
3. Empirical Analysis on the current situation of health financing and its equity in urban areas;
4. Empirical Analysis on the current situation of financial risk protection in urban areas;
5. Empirical Analysis on the current situation of individuals'health level in urban areas;
6. Providing suggestions and recommendations to improve the financing of the existing urban medical insurance system based on the analysis results.
Methods
1. The effect analysis framework of health financing system
In this study, we combined the framework of monitoring and evaluation of health system strengthening and the framework of health reform and development and discarded the evaluation indices of supplier side to evaluate and analyze the effect of health financing under the background of universal health coverage. Using the empirical data from the family health service survey, we inspected and evaluated the results chain from'promotion of universal health coverage','assessment of equity in health services utilization and health financing', to'assessment of impact on the health status and financial risk protection'.
2. Data Source
Household Survey
Based on the different geographical and economic development between Chinese provinces and the feasibility of data acquisition, we chose Hangzhou as the sample of eastern cities and Baoji as the sample of western cities from those first pilot cities having URBMI reform. We adopted a multi-stage stratified random sampling method to randomly select a certain number of households in the two cities and investigated all permanent residents in these families as samples of residents living in urban areas in China. In this study, household survey was organized in three consecutive years (2009,2010,2011). Data of health service utilizations and financing of family members was collected for continuous monitoring. The survey tried to revisit the same family in three years to control the impact of changes in populations.
Literature and policy data collection
International and domestic researches on universal health coverage and health financing were searched and collected. Important policy documents of the implementation and promotion of insurance system from central government, Baoji and Hangzhou municipal government were reviewed, as well as statistical data from the World Health Organization, the Ministry of Health, the Ministry of Human Resources and Social Security, Municipal Bureau of Health, Bureau of Labor and social Security and other government departments.
3. Analytical Methods
Literature review and summarizing
Through summarizing the collected literature, policy documents and other secondary data, the development of China's health insurance system, the inevitability of implementation of universal health coverage as well as the current situation of the health financing system were analyzed.
Analysis on equity in health service utilizations and health financing
Ratios comparison, Gini coefficient, concentration index, standardization of utilization of health services and HIwv, Kakwani index etc. were used to empirically analyze the equity in health service utilizations and health financing of resident samples.
Analysis on financial risk protection
Catastrophic health expenditure incidence and severity of catastrophic health expenditure were estimated to reflect the strength of the financial risk protection in the population under the existing health insurance and health financing system.
Analysis on health status of sample populations
Health related quality of life of residents aged15and over was measured by EQ-5D scales to evaluate the changes of the health status of urban residents.
Statistical analysis tools
Household survey data was input by Epidata3.1and was imported into SPSS18.0to run statistical analysis.
Results
1. The implementation of new healthcare reform played an important role in improving the construction of universal health coverage and health financing system in China
Prior to the implementation of the new healthcare reform, there were problems of inequality such as heavy burden of OOP payment, lack of medical insurance, low efficiency of resource allocation and use, regional and inter-system inequality in health financing in China's health systems and health financing system. After the implementation of the new healthcare reform in2009, China established the goal of universal health coverage. China's health financing system has also undergone a significant change in the sources of funding and financing forms. In the new healthcare reform, the important objective of health financing was to enlarge the function of government financial funding and financing of social insurance. Its purpose was to reduce the proportion of individual OOP payments. The goal of reform, in line with the requirements of the health financing system for universal health coverage, was praiseworthy.
2. China has established a basic universal health coverage system with wide coverage and good system construction
In this study, Hangzhou and Baoji were chosen as the representative samples of eastern and mid western cities. Until2011, the survey shows the basic health insurance coverage in the two cities has reached95%, which refers to the wide urban basic medical insurance coverage basically reaching the requirements of universal health coverage, revealing the tremendous achievements of the new healthcare reform. From the operation status, financing forms and security benefits of insurance systems in these two cities, the current systems were designed with different financing and benefit methods for different groups of people. The policies of URBMI in these two pilot cities were adjusted constantly in the past few years to gradually increase the level of financing and security benefits. This showed government's great determination to mitigate the medical and economic burden of the residents at the greatest extent.
3. Significant differences in health financing and security benefits were found between different regions, and different insurance systems
The medical insurance systems in different areas were managed by local government, which resulting the obvious gap of financing and security benefits between different regions caused by differences in the levels of social and economic development. Two types of urban basic insurances in Hangzhou both had higher security benefits at out-patient level, while the urban basic health insurance in Baoji was designed to mainly reimburse the in-patient services causing low compensation for out-patient services. In addition, the financing of URBMI was mainly from the investment of government budget funding and the financing level was far lower than UEBMI, which results the gap of the security benefits between two types of insurances. In terms of regional differences or inter-system differences, universal health coverage in China was carried out to be at the basic stage which can cause inequality between different groups of people.
4. There were disparities in the utilization of outpatient and inpatient services among people in different regions and with different insurances
Due to the differences in the health financing and security benefits of medical insurances between Hangzhou and Baoji, residents in these two cities had great differences in the utilization of outpatient and inpatient services. The health financing level was higher and the extent of protection in outpatient services was greater, thus a higher utilization of outpatient services was found in Hangzhou. The level of outpatient financing and protection was lower, which restricted residents to use outpatient services in Baoji. But the situation of hospitalization rate was the opposite. Year hospitalization rates in Baoji were higher than Hangzhou, reflecting that it may occur more utilization of hospital services to treat the outpatient diseases because of the relatively higher security benefit level for inpatient services than outpatient services in Baoji which resulting the increasing of hospitalization rate. We used methods of standardization of health services utilization to calculate the standardized outpatient and inpatient treatment times and analyzed the concentration index and HIwv index. The results showed that the equity in outpatient services utilization was good between populations with different economic levels in the past three years in two sampled cities, but hospital services utilization in the two cities was relatively unfair because population with higher economic levels used more hospital services. Current universal health coverage and health financing system did not make a fundamental improvement in the use of hospital services.
5. The proportion of OOP payment in medical expenses was still high in urban areas and differences between regions and insurance systems still existed
The data results showed that the gap between the levels of medical expenses caused by the differences of socio-economic development levels between eastern and western cities, which was more obvious in the cost of hospitalization. Based on the proportion of OOP payment in medical expenses, the level of security benefits for outpatient services was higher in Hangzhou and the proportion of OOP payment was only about35%. The compensation for outpatient treatment was lower in Baoji, especially for population with URBMI who basically had no reimbursement and relied on OOP payment to pay for outpatient services. The difference between reimbursement levels for hospitalization services was small between the two cities. The proportion of OOP payment was about40%in Hangzhou, while in Baoji the proportion was about45%. From the international experiences, the proportion of OOP payment in inpatient treatment costs was just barely reached the standard level of40%in China's urban areas, which means our universal health coverage was still at a very basic level. Comparing the two urban basic medical insurance system, the results showed that people with UEBMI had lower proportion of OOP payment whether in outpatient costs or inpatient costs than those with URBMI. The gap between different regions and health insurance systems meant the inequality in health financing in urban areas.
6. The equity and progressivity in health financing were poor in urban areas
This study used concentration index of health expenditures, Gini coefficients calculated using different measurement of economic level and Kakwani index and other indicators to evaluate the equity in health financing in China's urban areas. The results showed that the health financing system was still regressive under the universal health coverage system after the implementation of the new healthcare reform in China's urban areas. Various types of Kakwani indices were negative showing that the proportion of health financing in families with low economic level was higher than their corresponding proportion of family economic capacity which means the burden of health financing was heavier for families with low economic level. The results of redistributive effects analysis showed that the inequality in economic level distribution after health financing was larger than the distribution before financing. Regressivity of health financing also would more easily lead to occurrence of catastrophic health expenditure, thus affecting people's living standards and health status.
7. The incidence of household catastrophic health expenditures was still high in urban areas
The data showed that the incidence of catastrophic health expenditures was about11%in Hangzhou while about15%in Baoji, which means the OOP health expenditures have a great negative impact on the family life. Although the universal health coverage was widely expanded, health financing didn't lead to better protection of family's financial risk. The living standard of families with catastrophic health expenditure was significantly lower than those without catastrophic health expenditure. The proportion of health expenditures in household consumption expenditures was about60%in those families with CHE, much higher than the standard of40%. The concentration index of catastrophic health expenditure occurrence showed the occurrence of CHE in favor of the families with low economic level which means the protection of financial risk for those poor families was less ideal.
8. People's health status was not significantly improved in urban areas
This study used the EQ-5D scale to evaluate the health-related quality of life of surveyed population. The results showed that the overall EQ-5D VAS scores and EQ-5D index scores reflecting a good situation of average health status of urban residents in Hangzhou and Baoji. Regarding the revisit in three years, the survey may be affected by the decline of health level caused by the increased residents'age so that the two types of EQ-5D scores slightly decreased in the past three years. The existing results indicated that within three years after the implementation of the new healthcare reform, universal health coverage didn't substantially improve health status of urban residents and residents subjectively did not think their health levels had increased. It should be noted that due to the lag of improvement effect of policies on health status, self-cognitive health status of urban residents in a short time after the implementation of new healthcare reform reflected by the survey could not fully indicate the true state of health changes, which still need to be evaluated by long-term monitoring.
Suggestions
1. Government financial investment should be increased and the level of social insurance financing should be improved to decrease the proportion of OOP payments in medical expenses
In the past three years after the implementation of the new healthcare reform, government had invested850billion yuan for health system development, but investment did not fundamentally improve the inequality in residents' health financing regarding the changes in residents' health services utilization and health financing in urban areas. Therefore, the government should continue to invest the health system to not only ensure residents getting insured, but also further improve security benefits of basic medical insurances and reduce the proportion of OOP payments in health financing.
2. The efficiency of allocation and utilization of health resources should be focused when improving the equity in health financing
With the limited health resources, the government should support the development of primary health organizations, the delivery of public health services, basic health services and essential drugs, while exploring the payment reform for supply-side and controlling excessive demand for demand-side. Government should also promote the efficiency of health financing to improve the security benefits of the current universal health coverage system and equity in health financing through the implementation and management of various types of supporting policies relative to health financing.
3. Pooling between urban and rural areas and between different insurance systems should be promoted to enhance the pooling level and reduce the regional and inter-system differences
The differences between the different cities and different health insurance systems were the important reason causing inequality in health financing. Government should input more financial investment to the midwestern cities or other areas with lower socio-economic level to narrow the gap of security benefits between different regions. Meanwhile the security benefit level of URBMI should also be improved to move closer to the level of UEBMI, especially for the reimbursement level of outpatient services.
4. Progressive financing mechanisms could be introduced to the financing of health insurances.
The regressivity of the health financing system in China was partly due to that the current medical insurance system did not finance based on the individuals'economic level. Therefore insurance financing mechanism which meeting the equity requirements need to be established so that policies would be beneficial to poor population.
5. The role of medical assistance system should be strengthened to focus on the help for families with catastrophic health expenditure
CHE families had great impact on equity in health financing. Reducing the proportion of catastrophic expenditures families can significantly improve the equity in health financing. China's current medical assistance system had well developed. Estimate of catastrophic health expenditure can help to strengthen the role of medical assistance system to protect vulnerable populations. Furthermore, medical assistance should not only protect families after the happening of CHE, but also to help families to receive medical treatment when they facing high medical expenses.
6. Idea of universal health coverage and equity in health financing need to be established to strengthen the monitoring and evaluation
To achieve the cost and service dimension of universal health coverage, focus could not be just remained on the proportion of reimbursement of medical expenses and should be on health financing as a whole from the financing structure to the financing effects of the health financing system. Therefore, the mechanisms for monitoring and analysis of China's health financing system need to be established and become an important part of health system performance assessment.
WHO执行委员会于2005年提出了“全民覆盖”概念,也称作为“全民健康保险覆盖”或“全民医保”,即每个国家通过建立良好筹资的保障体系,保证所有公民能够在可负担的水平上获得必要的卫生服务。2010年,WHO进一步为“全民医保”的实现制定了操作指南,对任何一个国家来说,无论其发展水平,“全民医保”都应是其政策制定的优先目标。“全民医保”的实施需要解答政府、社会、个人应当怎样筹集资金来支付所发生的卫生服务,从而保证个人能够负担得起所需要的服务。由此可见,“全民医保”的基础是建立良好的卫生筹资体系。
卫生筹资体系通过税收、社会医疗保险等形式筹集社会公共资源,在不同健康状况、不同支付能力的人群中进行分摊,并利用这些筹集的资源向卫生服务提供方购买服务。卫生筹资的目标之一是使不同人群间经济负担趋向于公平。筹资公平性可分为水平公平和垂直公平：水平公平是指具有相同支付能力的人应支付相同的费用；垂直公平是指具有不同支付能力的人支付的卫生费用不同,支付能力高的人应该支付更多的费用。在全民医保实施下采取合理的筹资方式,能够有效地起到保障个人或家庭财务风险的作用,使人们在有卫生服务需求时能及时获得服务,最终促进人群的总体健康水平,达到“全民健康”的目的。
新中国的医疗保障制度建立至今已有60余年,回顾其历史,从建国后的公费、劳保医疗制度、农村合作医疗制度到后来的城镇职工/居民医疗保险制度、新型农村合作医疗制度,我国的医保制度经历了起起落落的几个阶段。在全民医保的开展之前,我国医保覆盖面较低,看病贵、看病难问题突出,个人现金支付的比例不断上升,成为卫生筹资的主要问题。WH02000年的报告表明,当时我国的卫生筹资公平性在191个成员国中排在188位,卫生筹资公平性非常不理想。而在2009年的新医改之后,我国开始了“全民医保”的全面推进。虽然在制度建设、筹资水平、保障水平等问题上还存在诸多挑战,但“全民医保”的基本实现已经成为现实。
21世纪初我国卫生筹资公平性的下降引起了国内许多学者的重视,涌现了许多以卫生筹资及其公平性作为重点内容的研究,在理论上及分析评价方法上都取得了较大进展。2003年之后,随着新农合的改革以及城镇职工基本医疗保险的不断推进,我国卫生筹资的公平性有了明显改善。关于新农合的研究表明,新农合改善了各个收入层次人群的卫生服务利用,降低了农民的灾难性卫生支出风险。而针对我国城镇地区人群的卫生筹资研究主要反映的是城镇居民医保实施前的情况,现有研究缺乏对新形势下,有其是新医改实施后城镇地区卫生筹资的评价。并且现有研究利用专门针对城镇地区人群卫生服务利用及筹资状况的数据较少。因此,评估新医改启动后“全民医保”基本实现的前提下,我国城镇地区卫生筹资及公平性现状以及评价城镇地区医保改革带来的影响是非常重要的。
二、研究目的
本研究以我国推进“全民医保”过程中实行城镇居民基本医疗保险改革的典型试点城市为样本,结合卫生改革的筹资理论,以城镇居民家庭为视角,通过对居民卫生服务利用以及家庭经济状况、生活支出的考察,评估和研究我国城镇地区在基本实现“全民医保”后,当前卫生筹资体系下城镇人群卫生服务利用与卫生筹资公平性及财务风险保护情况的变化,为城镇地区基本医疗保险制度的发展和完善提供现实参考。具体目标包括：
1.基于卫生改革的筹资理论,描述分析我国“全民医保”制度在城镇地区的发展、挑战和存在的问题,以及全民医保制度的筹资体系现状；
2.实证分析全民医保背景下城镇人群的卫生服务利用及公平性现状；
3.实证分析全民医保背景下城镇人群的卫生筹资及公平性现状；
4.实证分析全民医保背景下城镇人群的财务风险保护现状；
5.实证分析全民医保背景下城镇人群的健康水平及促进现状；
6.针对分析结果提出改善我国现有城镇医保制度筹资方式的建议。
三、研究方法
(一)卫生筹资体系的效应分析框架
本研究将卫生系统强化的监测和评价框架与卫生改革发展框架相结合,同时舍去原有框架中针对供方的评价内容,来评价和分析我国全民医保推进下卫生筹资体系的效应。利用家庭卫生服务调查的实证数据,对“全民医保推进”——“城镇居民卫生服务利用、筹资公平性评价”——“城镇居民健康状况、财务风险保护的影响”这一结果链进行综合考察和评价。
(二)资料来源
1.抽样调查
本研究根据中国各省市不同的地理位置和经济发展状况,选择第一批居民医保试点城市中的西部和东部城市各一个作为研究对象,并根据项目开展、资料获取的可行性,在西部试点城市中选择陕西省宝鸡市作为样本城市,在东部试点城市中选择浙江省杭州市作为样本城市。采取多阶段分层随机抽样的方法,在两个城市中随机选取一定数量的居民家庭,并以家庭中全体城镇户籍居民为调查对象(常住非户籍居民不纳入调查),作为我国城镇地区居民的样本代表,分析其卫生服务利用及筹资现状。本研究通过连续三年(2009、2010、2011)的入户调查,对两个样本城市家庭成员的相关卫生服务利用及筹资数据进行连续性收集和监测。同时调查根据第一轮调查进行回访的原则,考察同一家庭在三年内的变化情况。
2.二手资料收集
包括查阅国内外全民医保及卫生筹资研究,回顾中央政府、宝鸡市和杭州市政府关于城镇地区医疗保险制度实施、推进等重要政策文件,以及查找世界卫生组织网站、国家卫生部、人力资源与社会保障部、样本市卫生局、劳动及社会保障局等主要政府部门数据统计结果。
(三)分析方法
1.文献回顾及归纳
对收集的文献及政策文件等二手资料进行归纳和总结,分析我国医保体系的发展过程及“全民医保”实施的必然性,以及卫生筹资系统的现状。
2.卫生服务利用及卫生筹资的公平性分析
通过比率比较、Gini系数、集中指数、卫生服务利用的标准化及水平不公平指数、Kakwani指数等对样本居民的卫生服务利用和卫生筹资公平性做实证分析。
3.财务风险保护分析
测算灾难性卫生支出发生率,分析家庭遭遇灾难性卫生支出打击的严重程度等,反映现有医保及卫生筹资系统下人群受财务风险保护的强度。
4.人群健康状况分析
以欧洲五维健康量表(EQ-5D)进行测量,描述15岁及以上居民的健康相关生命质量,考察居民健康水平的变化。
5.统计分析工具
家庭入户调查资料以Epidata3.1进行录入,并导入SPSS18.0进行统计分析。
四、研究结果
(一)新医改实施对我国全民医保建设和卫生筹资系统完善起到了重要作用
在新医改实施前,我国的卫生系统和卫生筹资上存在着个人支出负担较重、医疗保险保障不足、资源配置和利用效率较低、地区及制度间卫生筹资不公平的问题。随着2009年开始的新医改实施,我国首次明确了“全民医保”的目标,在新医改实施下我国卫生筹资体系也发生了重要的改变,从筹资来源和筹资形式上来说,新医改下卫生筹资的重要目标是放大政府财政筹资和社会保险筹资的功能,其目的是要降低个
人现金支付的比例,符合了全民医保卫生筹资体系建设的要求,值得称道。(二)我国已建立基本的全民医保体系且覆盖面较广、制度建立较完善
本研究以杭州和宝鸡作为东部城市中西部城市的样本代表,调查显示两城市的基本医保覆盖面已达到95%以上,样本城市的城镇基本医保的覆盖情况非常良好,从覆盖面上来说基本达到了全民医保的要求,显现了新医改后全民医保取得的巨大成就。从两个城市的医保制度运行情况、筹资方式及保障待遇上来看,目前的城镇基本医保制度能够针对不同的人群设计不同的筹资及保障方式。两个城市作为城镇居民医保改革试点的第一批城市,居民医保的政策也在这几年间不断的调整,筹资水平和保障待遇逐步提高,表现了政府尽最大可能来减轻居民的医疗经济负担的决心。
(三)不同地区间、不同医保制度间的卫生筹资及保障待遇差异明显
我国目前不同地区的医保采取属地化管理,各地社会经济发展水平的差异使不同地区间的筹资及保障待遇差距明显。保障待遇方面杭州两类城镇基本保险的门诊保障水平都较高,宝鸡的城镇基本医保则主要是“保大病”,门诊方面的补偿待遇较低。此外,居民医保的筹资主要由政府财政投入,筹资水平远不如职工医保,因而导致两类医保人群在保障待遇上的差距。无论从地区差异还是制度差异来说,我国目前的全民医保还仅处于最基本的阶段,不同人群的差距容易造成不公平的现象。
(四)不同地区及医保参保人群间的门诊及住院服务利用存在差异
由于杭州和宝鸡在卫生筹资及医保保障制度上的差异,使两个城市居民的门诊和住院服务利用产生了较大的区别。杭州的卫生筹资水平较高,对门诊的保障力度较大,因而杭州的门诊服务利用率较高。而宝鸡在门诊方面的筹资水平较低,保障水平也较低,制约了宝鸡居民门诊服务的使用。但住院率上则呈相反的情况,宝鸡年住院率反而高于杭州,反映出宝鸡居民由于住院保障力度相对门诊高,可能发生多利用住院服务来治疗原本能够通过门诊治疗的疾病,导致了住院率的上升。本研究利用卫生服务标准化的方法计算了门诊和住院次数的集中指数和HIwv指标,结果反映近三年来两个样本城市门诊服务利用在不同经济水平人群中的公平性较为良好,但住院服务利用上两个城市都存在不公平的现象,经济水平高的人群能更多的使用住院服务。目前的全民医保体系和卫生筹资水平对住院服务的使用并没有起到根本性的改善。
(五)城镇地区医疗费用个人承担比例仍较高且存在地区和制度间的差异
数据结果显示了由东西部城市社会经济水平的差异所导致的医疗费用水平上的差距,这一差距在住院费用上体现的更加明显。从医疗费用个人承担比例上看,杭州的门诊保障待遇水平较高,个人需要承担的自付费用比例仅在35%左右；宝鸡的门诊补偿待遇则较低,尤其是居民医保基本上没有实质性的医保报销,基本上全部依靠个人自付来承担。住院保障上两个城市之间的差异较小,杭州个人承担的比例在40%左右,宝鸡个人承担比例在45%左右。从个人承担比例上看我国全民医保就保障力度而言仍然处于非常基础的水平。而比较两类城镇基本医保制度,结果显示职工医保无论是门诊还是住院其个人承担的比例都比居民医保要低。不同地区和医保制度间的差距,意味着城镇地区卫生筹资存在水平不公平现象。
(六)城镇地区卫生筹资的公平性及累进性较差
通过各类卫生支出集中指数、各类经济能力衡量标准的Gini系数以及Kakwani指数等指标来评价目前我国城镇地区卫生筹资的公平性,结果显示新医改实施后全民医保体系下我国目前城镇地区的卫生筹资仍然属于累退性。各类Kakwani指数都呈负值说明卫生筹资在低经济水平家庭中的比重要高于其所对应的经济能力的比重,对于低经济水平家庭来说卫生筹资的负担更重。通过再分配效应分析,结果表明筹资后的经济水平分布比筹资前的不公平程度加剧,卫生筹资的累退性带来的不公平也容易引起灾难性卫生支出的发生,从而影响人群的生活水平和健康状况。
(七)城镇地区家庭灾难性卫生支出发生率仍较高
数据结果显示杭州的灾难性卫生支出发生率在11%左右,宝鸡的发生率为15%左右,这一结果表明目前我国家庭的现金卫生支出对家庭生活水平带来的负面影响较大,虽然全民医保的覆盖面较广,但通过卫生筹资并没有给家庭的财务风险带来较好的保障。灾难性卫生支出家庭的生活水平明显低于未发生灾难性卫生支出的家庭,其卫生支出占家庭消费支出的比例平均在60%,与界定标准40%的差距较大。是否发生灾难性卫生支出的集中指数显示了灾难性卫生支出的发生比较偏向于低经济水平的家庭,低水平家庭的财务风险保护状况较为不理想。
(八)城镇地区人群健康状况变化未显示明显的改善
利用EQ-5D量表对调查人群的健康相关生命质量进行评价,总体上EQ-5D的VAS得分和指数得分反映杭州和宝鸡城镇居民的平均健康水平尚处于良好的水平。考虑到本研究三年间采用回访的方式进行调查,可能受回访居民年龄增长带来的健康水平下降的影响,EQ-5D两类得分都显示了三年间略有降低的情况。现有结果说明新医改实施后的三年内,全民医保的覆盖并没有给城镇居民带来实质性的健康状况改善,居民主观上并未认为自己的健康水平有所提高。需要指出的是由于政策对于健康状况的改善效应有其滞后性,在新医改实施后的前三年短时期内,通过调查数据反映出的居民自我认知状况尚不能充分反映真实的健康状况改变,仍需要通过长期的监测来评价居民的健康状况改善。
五、政策建议
(一)加大政府投入和提高社会保险筹资水平,降低医疗费用个人承担比例新医改实施后的近3年政府已经投入8500亿元用于卫生事业发展,但从城镇地区居民的服务利用和卫生筹资变化上看,投入仍然没有根本改变居民卫生筹资的不公平状况。因此,政府的大力投入应当继续保持,不仅需要保证居民的参保,还需要进一步提高居民的医保保障待遇,进一步降低卫生筹资中个人承担的比例。
(二)在提高卫生筹资公平性的同时注重卫生筹资的配置和使用效率
在目前卫生筹资资源有限的情况下,政府应坚定不移的支持基层卫生机构的发展,支持公共卫生服务、基本卫生服务、基本药物的提供,同时探索供方支付方式改革、需方过度服务需求的控制等,通过与卫生筹资相关的各类配套政策的实施和管理,促进卫生筹资的效率,提高全民医保体系的保障力度和卫生筹资的公平性。
(三)推动城乡统筹和制度统筹,提升统筹层次,缩小区域性差异和制度性差异
不同城市间的区域差异和不同医保制度之间的差异是造成卫生筹资水平不公平的重要原因。政府应着重对中西部城市或其他社会经济水平较低的区域的财政投入,缩小不同区域间的保障水平差距；同时继续提高居民医保的保障水平,使其向职工医保的保障待遇靠拢,尤其针对居民医保门诊的保障应逐步提高补偿水平,缩小不同医保人群的保障待遇差距。
(四)在医保筹资中引入累进性的筹资机制
目前我国卫生筹资体系的累退性,一部分原因是医疗保障制度实施中并没有根据个人的经济水平采取不同的筹资比例,因此需要建立符合公平要求的医疗保障筹资机制,做到政策向低收入者和贫困人群倾斜。
(五)强化医疗救助作用,重点帮助灾难性卫生支出家庭
灾难性支出家庭对于卫生筹资公平性的影响非常大,降低灾难性支出家庭的比例可以明显改善家庭卫生筹资的公平性。目前我国的医疗救助制度已经发展相对较为成熟,通过对灾难性卫生支出的测算,可以更好的有针对性的发挥医疗救助制度对弱势人群的保障力度。此外,不仅要强化医疗救助的事后救助,还要建立医疗救助的事先救助,帮助面临高额医疗费用家庭接受所需要的医疗服务。
(六)树立全民医保和卫生筹资公平性理念,加强监测与评估
对于全民医保费用和服务保障维度的实现,不能只停留在关注医保政策范围内医疗费用报销比例和医疗费用实际报销比例,而是需要着眼于卫生筹资的整体,关注整个卫生筹资体系的筹资结构和筹资效应。因此需要建立对于我国卫生筹资体系的监测与分析机制,使其成为卫生系统绩效评估的重要组成部分。
Background
WHO Executive Committee proposed the concept of'Universal Coverage'in2005, also known as'Universal Health Insurance Coverage'or'Universal Health Coverage'. It refers to countries ensuring all citizens to obtain the necessary health services under an affordable level through the establishment of a good financed insurance system. In2010, WHO further developed an operation guide for achieving universal health coverage. For any country regardless of their development level, universal health coverage should be the priority objectives of its policy-making. The implementation of universal health coverage needs to answer the question that how to raise funds to pay for health services from government, society and individuals and to ensure individuals being able to afford those services. Thus, the basis of'universal coverage'is to establish a good health financing system.
A health financing system raises public resources through taxation, social health insurance and other forms, shares them in individuals with different health status and ability to pay, and uses these resources to purchase services from health service providers. One of the objectives of health financing is to make the economic burden between different groups of people tend to be fair. Equity in health financing can be divided into horizontal equity and vertical equity. Horizontal equity means those have same ability to pay should pay the same fees. Vertical equity means people with different ability to pay should bear different health costs. Adopting reasonable means of financing when implementing universal health coverage can effectively protect the financial risk so that people can use services timely when they have the health service needs, and ultimately promote the overall health of population and achieve the goal of'health for all'.
The medical insurance system in China has established for more than60years. Reviewing its history, the system has undergone several stages from public funded medical care, labor protection medical care, the rural cooperative medical system to the urban employees/residents basic medical insurance (UEBMI/URBMI), the new rural cooperative medical care system (NCMS). Before the promotion of universal health coverage, the low health insurance coverage in China and the increasing proportion of out-of-pocket (OOP) payments become the main problems in health financing. In2000, WHO report shows that China's equity in health financing ranked188in the191member states, which was far from ideal. After a new healthcare reform in2009, China began to comprehensively promote universal health coverage. Although there are still many challenges in the system construction, funding levels, protection levels and other issues, the basic achieving of universal health coverage has become a reality.
In the early21st century, the declining of equity in health financing aroused the attention of many domestic scholars. The emergence of researches focusing on health financing and equity had made great progresses both in theory and the analysis methods. After2003, the equity in health financing in China has been significantly improved as to the reform of the new rural cooperative medical care system and urban employees basic medical insurance. Studies on new rural cooperative medical care system showed that it improved health services utilization for people with different income levels and reduced farmers' catastrophic health expenditure (CHE) risk. Studies on health financing in China's urban areas reflected the situation prior to the implementation of urban residents basic medical insurance. There are few existing researches focusing on the new situation, especially after the implementation of the new healthcare reform. And less existing researches used data of health services utilization and the financing status specifically for urban areas. Therefore, it is important to assess the current situation of equity in health financing and the impact of insurance reform under the background of universal health coverage after the new healthcare reform in China's urban areas.
Objectives
This study chose the typical pilot cities implementing the urban residents basic medical insurance reform as samples. Combined with the theory of financing in health reform, we took the perspective of urban households and investigated the utilization of health services and family economic conditions. The objective was to assess the changes in utilization of health services, equity in health financing and the protection of financial risk of urban populations in the current health financing system after the basic achieving of universal health coverage. Policy suggestions would be provided to promote the development of the basic medical insurance system in urban areas.
Specific objectives include:
1. Based on the theory of financing in the health reform, describing and analyzing the development, challenges and existing problems of universal health coverage in China, as well as the current situation of health financing system;
2. Empirical Analysis on the current situation of utilization of health services and its equity in urban areas;
3. Empirical Analysis on the current situation of health financing and its equity in urban areas;
4. Empirical Analysis on the current situation of financial risk protection in urban areas;
5. Empirical Analysis on the current situation of individuals'health level in urban areas;
6. Providing suggestions and recommendations to improve the financing of the existing urban medical insurance system based on the analysis results.
Methods
1. The effect analysis framework of health financing system
In this study, we combined the framework of monitoring and evaluation of health system strengthening and the framework of health reform and development and discarded the evaluation indices of supplier side to evaluate and analyze the effect of health financing under the background of universal health coverage. Using the empirical data from the family health service survey, we inspected and evaluated the results chain from'promotion of universal health coverage','assessment of equity in health services utilization and health financing', to'assessment of impact on the health status and financial risk protection'.
2. Data Source
Household Survey
Based on the different geographical and economic development between Chinese provinces and the feasibility of data acquisition, we chose Hangzhou as the sample of eastern cities and Baoji as the sample of western cities from those first pilot cities having URBMI reform. We adopted a multi-stage stratified random sampling method to randomly select a certain number of households in the two cities and investigated all permanent residents in these families as samples of residents living in urban areas in China. In this study, household survey was organized in three consecutive years (2009,2010,2011). Data of health service utilizations and financing of family members was collected for continuous monitoring. The survey tried to revisit the same family in three years to control the impact of changes in populations.
Literature and policy data collection
International and domestic researches on universal health coverage and health financing were searched and collected. Important policy documents of the implementation and promotion of insurance system from central government, Baoji and Hangzhou municipal government were reviewed, as well as statistical data from the World Health Organization, the Ministry of Health, the Ministry of Human Resources and Social Security, Municipal Bureau of Health, Bureau of Labor and social Security and other government departments.
3. Analytical Methods
Literature review and summarizing
Through summarizing the collected literature, policy documents and other secondary data, the development of China's health insurance system, the inevitability of implementation of universal health coverage as well as the current situation of the health financing system were analyzed.
Analysis on equity in health service utilizations and health financing
Ratios comparison, Gini coefficient, concentration index, standardization of utilization of health services and HIwv, Kakwani index etc. were used to empirically analyze the equity in health service utilizations and health financing of resident samples.
Analysis on financial risk protection
Catastrophic health expenditure incidence and severity of catastrophic health expenditure were estimated to reflect the strength of the financial risk protection in the population under the existing health insurance and health financing system.
Analysis on health status of sample populations
Health related quality of life of residents aged15and over was measured by EQ-5D scales to evaluate the changes of the health status of urban residents.
Statistical analysis tools
Household survey data was input by Epidata3.1and was imported into SPSS18.0to run statistical analysis.
Results
1. The implementation of new healthcare reform played an important role in improving the construction of universal health coverage and health financing system in China
Prior to the implementation of the new healthcare reform, there were problems of inequality such as heavy burden of OOP payment, lack of medical insurance, low efficiency of resource allocation and use, regional and inter-system inequality in health financing in China's health systems and health financing system. After the implementation of the new healthcare reform in2009, China established the goal of universal health coverage. China's health financing system has also undergone a significant change in the sources of funding and financing forms. In the new healthcare reform, the important objective of health financing was to enlarge the function of government financial funding and financing of social insurance. Its purpose was to reduce the proportion of individual OOP payments. The goal of reform, in line with the requirements of the health financing system for universal health coverage, was praiseworthy.
2. China has established a basic universal health coverage system with wide coverage and good system construction
In this study, Hangzhou and Baoji were chosen as the representative samples of eastern and mid western cities. Until2011, the survey shows the basic health insurance coverage in the two cities has reached95%, which refers to the wide urban basic medical insurance coverage basically reaching the requirements of universal health coverage, revealing the tremendous achievements of the new healthcare reform. From the operation status, financing forms and security benefits of insurance systems in these two cities, the current systems were designed with different financing and benefit methods for different groups of people. The policies of URBMI in these two pilot cities were adjusted constantly in the past few years to gradually increase the level of financing and security benefits. This showed government's great determination to mitigate the medical and economic burden of the residents at the greatest extent.
3. Significant differences in health financing and security benefits were found between different regions, and different insurance systems
The medical insurance systems in different areas were managed by local government, which resulting the obvious gap of financing and security benefits between different regions caused by differences in the levels of social and economic development. Two types of urban basic insurances in Hangzhou both had higher security benefits at out-patient level, while the urban basic health insurance in Baoji was designed to mainly reimburse the in-patient services causing low compensation for out-patient services. In addition, the financing of URBMI was mainly from the investment of government budget funding and the financing level was far lower than UEBMI, which results the gap of the security benefits between two types of insurances. In terms of regional differences or inter-system differences, universal health coverage in China was carried out to be at the basic stage which can cause inequality between different groups of people.
4. There were disparities in the utilization of outpatient and inpatient services among people in different regions and with different insurances
Due to the differences in the health financing and security benefits of medical insurances between Hangzhou and Baoji, residents in these two cities had great differences in the utilization of outpatient and inpatient services. The health financing level was higher and the extent of protection in outpatient services was greater, thus a higher utilization of outpatient services was found in Hangzhou. The level of outpatient financing and protection was lower, which restricted residents to use outpatient services in Baoji. But the situation of hospitalization rate was the opposite. Year hospitalization rates in Baoji were higher than Hangzhou, reflecting that it may occur more utilization of hospital services to treat the outpatient diseases because of the relatively higher security benefit level for inpatient services than outpatient services in Baoji which resulting the increasing of hospitalization rate. We used methods of standardization of health services utilization to calculate the standardized outpatient and inpatient treatment times and analyzed the concentration index and HIwv index. The results showed that the equity in outpatient services utilization was good between populations with different economic levels in the past three years in two sampled cities, but hospital services utilization in the two cities was relatively unfair because population with higher economic levels used more hospital services. Current universal health coverage and health financing system did not make a fundamental improvement in the use of hospital services.
5. The proportion of OOP payment in medical expenses was still high in urban areas and differences between regions and insurance systems still existed
The data results showed that the gap between the levels of medical expenses caused by the differences of socio-economic development levels between eastern and western cities, which was more obvious in the cost of hospitalization. Based on the proportion of OOP payment in medical expenses, the level of security benefits for outpatient services was higher in Hangzhou and the proportion of OOP payment was only about35%. The compensation for outpatient treatment was lower in Baoji, especially for population with URBMI who basically had no reimbursement and relied on OOP payment to pay for outpatient services. The difference between reimbursement levels for hospitalization services was small between the two cities. The proportion of OOP payment was about40%in Hangzhou, while in Baoji the proportion was about45%. From the international experiences, the proportion of OOP payment in inpatient treatment costs was just barely reached the standard level of40%in China's urban areas, which means our universal health coverage was still at a very basic level. Comparing the two urban basic medical insurance system, the results showed that people with UEBMI had lower proportion of OOP payment whether in outpatient costs or inpatient costs than those with URBMI. The gap between different regions and health insurance systems meant the inequality in health financing in urban areas.
6. The equity and progressivity in health financing were poor in urban areas
This study used concentration index of health expenditures, Gini coefficients calculated using different measurement of economic level and Kakwani index and other indicators to evaluate the equity in health financing in China's urban areas. The results showed that the health financing system was still regressive under the universal health coverage system after the implementation of the new healthcare reform in China's urban areas. Various types of Kakwani indices were negative showing that the proportion of health financing in families with low economic level was higher than their corresponding proportion of family economic capacity which means the burden of health financing was heavier for families with low economic level. The results of redistributive effects analysis showed that the inequality in economic level distribution after health financing was larger than the distribution before financing. Regressivity of health financing also would more easily lead to occurrence of catastrophic health expenditure, thus affecting people's living standards and health status.
7. The incidence of household catastrophic health expenditures was still high in urban areas
The data showed that the incidence of catastrophic health expenditures was about11%in Hangzhou while about15%in Baoji, which means the OOP health expenditures have a great negative impact on the family life. Although the universal health coverage was widely expanded, health financing didn't lead to better protection of family's financial risk. The living standard of families with catastrophic health expenditure was significantly lower than those without catastrophic health expenditure. The proportion of health expenditures in household consumption expenditures was about60%in those families with CHE, much higher than the standard of40%. The concentration index of catastrophic health expenditure occurrence showed the occurrence of CHE in favor of the families with low economic level which means the protection of financial risk for those poor families was less ideal.
8. People's health status was not significantly improved in urban areas
This study used the EQ-5D scale to evaluate the health-related quality of life of surveyed population. The results showed that the overall EQ-5D VAS scores and EQ-5D index scores reflecting a good situation of average health status of urban residents in Hangzhou and Baoji. Regarding the revisit in three years, the survey may be affected by the decline of health level caused by the increased residents'age so that the two types of EQ-5D scores slightly decreased in the past three years. The existing results indicated that within three years after the implementation of the new healthcare reform, universal health coverage didn't substantially improve health status of urban residents and residents subjectively did not think their health levels had increased. It should be noted that due to the lag of improvement effect of policies on health status, self-cognitive health status of urban residents in a short time after the implementation of new healthcare reform reflected by the survey could not fully indicate the true state of health changes, which still need to be evaluated by long-term monitoring.
Suggestions
1. Government financial investment should be increased and the level of social insurance financing should be improved to decrease the proportion of OOP payments in medical expenses
In the past three years after the implementation of the new healthcare reform, government had invested850billion yuan for health system development, but investment did not fundamentally improve the inequality in residents' health financing regarding the changes in residents' health services utilization and health financing in urban areas. Therefore, the government should continue to invest the health system to not only ensure residents getting insured, but also further improve security benefits of basic medical insurances and reduce the proportion of OOP payments in health financing.
2. The efficiency of allocation and utilization of health resources should be focused when improving the equity in health financing
With the limited health resources, the government should support the development of primary health organizations, the delivery of public health services, basic health services and essential drugs, while exploring the payment reform for supply-side and controlling excessive demand for demand-side. Government should also promote the efficiency of health financing to improve the security benefits of the current universal health coverage system and equity in health financing through the implementation and management of various types of supporting policies relative to health financing.
3. Pooling between urban and rural areas and between different insurance systems should be promoted to enhance the pooling level and reduce the regional and inter-system differences
The differences between the different cities and different health insurance systems were the important reason causing inequality in health financing. Government should input more financial investment to the midwestern cities or other areas with lower socio-economic level to narrow the gap of security benefits between different regions. Meanwhile the security benefit level of URBMI should also be improved to move closer to the level of UEBMI, especially for the reimbursement level of outpatient services.
4. Progressive financing mechanisms could be introduced to the financing of health insurances.
The regressivity of the health financing system in China was partly due to that the current medical insurance system did not finance based on the individuals'economic level. Therefore insurance financing mechanism which meeting the equity requirements need to be established so that policies would be beneficial to poor population.
5. The role of medical assistance system should be strengthened to focus on the help for families with catastrophic health expenditure
CHE families had great impact on equity in health financing. Reducing the proportion of catastrophic expenditures families can significantly improve the equity in health financing. China's current medical assistance system had well developed. Estimate of catastrophic health expenditure can help to strengthen the role of medical assistance system to protect vulnerable populations. Furthermore, medical assistance should not only protect families after the happening of CHE, but also to help families to receive medical treatment when they facing high medical expenses.
6. Idea of universal health coverage and equity in health financing need to be established to strengthen the monitoring and evaluation
To achieve the cost and service dimension of universal health coverage, focus could not be just remained on the proportion of reimbursement of medical expenses and should be on health financing as a whole from the financing structure to the financing effects of the health financing system. Therefore, the mechanisms for monitoring and analysis of China's health financing system need to be established and become an important part of health system performance assessment.
引文
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