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  本文關(guān)鍵詞： 乙型肝炎 直接醫(yī)療費用 醫(yī)療保險 門診 政策　出處：《東南大學》2017年碩士論文　論文類型：學位論文

【摘要】：目的分析乙肝患者的直接醫(yī)療費用及其構(gòu)成、影響因素,探討乙肝患者醫(yī)療保險門診政策的實施現(xiàn)狀及存在的主要問題,提出減輕乙肝患者經(jīng)濟負擔的合理措施,為完善醫(yī)療保險政策提供依據(jù)。方法通過圖書館、互聯(lián)網(wǎng)、政府平臺等搜集江蘇省部分地區(qū)醫(yī)保門診政策的相關(guān)文件和管理辦法,并進行歸納和整理。描述江蘇省13個統(tǒng)籌地區(qū)職工醫(yī)保、居民醫(yī)保和新農(nóng)合的醫(yī)保門診政策現(xiàn)狀,包括醫(yī)保門診病種設(shè)置、乙肝患者的保障情況以及政策的具體實施情況(待遇水平、支付方式等)。對江蘇省2所三級醫(yī)院感染科的乙肝就診患者50人和3所三級醫(yī)院感染科的臨床醫(yī)生5人進行訪談,了解乙肝患者年人均門診就診次數(shù)以及醫(yī)生對《乙肝防治指南》的解讀和應(yīng)用情況。選取江蘇省2所三級醫(yī)院2014年1～12月14910人次門診乙肝患者和966人次住院乙肝患者作為實證研究樣本,從醫(yī)院病例病案系統(tǒng)獲取患者的直接醫(yī)療費用及就診信息。描述門診和住院乙肝患者的直接醫(yī)療費用及其構(gòu)成、次均直接醫(yī)療費用、年門診費用、醫(yī)保報銷費用和報銷比例等;對乙肝患者的直接醫(yī)療費用、住院天數(shù)進行單因素分析;對住院乙肝患者直接醫(yī)療費用進行多元線性回歸分析。結(jié)果1.乙肝患者直接醫(yī)療費用(1)門診乙肝患者在14910人次門診乙肝病例中,男性8952人次(60.04%),女性5958人次(39.96%);25～34歲年齡組就診人次最多(4131人次),占27.71%,0～14歲年齡組最少(56人次),占0.38%;醫(yī)�；颊�9940人次(66.67%),繳費患者4970人次(33.33%);在醫(yī)�；颊咧�,職工醫(yī)�；颊�9830人次(98.89%),居民醫(yī)保患者110人次(1.11%);患者抗病毒治療率為37.46%,職工醫(yī)�；颊呖共《局委熉�(37.80%)高于居民醫(yī)�；颊�(29.09%)。14910人次門診乙肝病例直接醫(yī)療費用總額為14188409.81元。次均門診費用為951.60元,其中藥品費比重最高(790.27元),占83.05%;年人均門診就診次數(shù)為12次,年人均門診費用為11419.20元;次均門診費用男性(997.71元)高于女性(882.32元),差異有統(tǒng)計學意義(P0.05);30～59歲年齡組(980.33元)最高,差異有統(tǒng)計學意義(P0.05);職工醫(yī)保患者(953.22元)高于居民醫(yī)�；颊�(811.05元),差異有統(tǒng)計學意義(P0.05);抗病毒治療患者(1094.77元)高于未抗病毒治療患者(865.86元),差異有統(tǒng)計學意義(P0.05);患者次均報銷比例為62.32%,職工醫(yī)保患者(62.51%)高于居民醫(yī)�；颊�(42.76%),差異有統(tǒng)計學意義(P0.05)。(2)住院乙肝患者在966人次住院乙肝病例中,男性649人次(67.18%),女性317人次(32.82%);25～34歲年齡組住院患者最多(339人次),占35.09%,0～14歲年齡組最少(11人次),占1.14%;醫(yī)�；颊�554人次(57.35%),繳費患者412人次(42.65%)。在醫(yī)�；颊咧�,職工醫(yī)保患者526人次(94.95%),居民醫(yī)�；颊�28人次(5.05%);患者抗病毒治療率為38.61%,職工醫(yī)保患者抗病毒治療率(39.35%)高于居民醫(yī)�；颊�(32.14%);住院天數(shù)平均24.78±16.81天,最多為15～29天住院天數(shù)組(416人次),占43.06%,最少為≥60天住院天數(shù)組(51人次),占5.28%;住院天數(shù)(中位數(shù))男性(21天)多于女性(19天),差異有統(tǒng)計學意義(P0.05);醫(yī)保患者(24天)多于繳費患者(17天),差異有統(tǒng)計學意義(P0.05);職工醫(yī)�；颊�(24天)多于居民醫(yī)保患者(22.5天),差異有統(tǒng)計學意義(P0.05)。966人次住院乙肝病例直接醫(yī)療費用總額為12714108.85元。次均住院費用13161.60元,其中藥品費比重最高(9025.09元),占68.57%;次均住院費用男性(13711.37元)高于女性(12036.05元),差異有統(tǒng)計學意義(P0.05);30天及以上住院天數(shù)組(18255.02元)高于其他住院天數(shù)組,不同住院天數(shù)組間費用差異有統(tǒng)計學意義(P0.05);醫(yī)�；颊�(14153.12元)高于繳費患者(11828.35元),差異有統(tǒng)計學意義(P0.05);重度乙肝患者(17256.20元)最高,中度乙肝患者(12827.62元)次之,輕度乙肝患者(11628.48元)最低,不同疾病嚴重程度組間費用差異有統(tǒng)計學意義(P0.05);抗病毒治療患者(13957.82元)高于未抗病毒治療患者(12660.78元);患者次均報銷比例為70.45%,職工醫(yī)保患者(70.88%)高于居民醫(yī)�；颊�(60.95%),差異有統(tǒng)計學意義(P0.05);多元逐步回歸分析顯示,住院天數(shù)、疾病嚴重程度、抗病毒治療、結(jié)算方式是住院費用的影響因素(P0.05)。2.醫(yī)保門診政策現(xiàn)狀及乙肝患者保障情況江蘇省各統(tǒng)籌地區(qū)的醫(yī)保門診政策項目名稱各不相同,主要有門診慢性病、門診特殊病、門診大病等;門診病種數(shù)量差異較大,多則幾十種,少則只有幾種。在13個研究地區(qū)的醫(yī)保門診政策中,職工醫(yī)保有12個地區(qū)將乙肝納入保障范圍,居民醫(yī)保只有5個地區(qū)納入乙肝,新農(nóng)合則有9個地區(qū)將乙肝納入范圍;各地政策規(guī)定的乙肝疾病類型也有所不同,一些地區(qū)包括所有乙肝相關(guān)疾病,有的地區(qū)只包括部分乙肝相關(guān)疾病,如肝硬化失代償期、重型肝炎等。不同地區(qū)之間、同一地區(qū)的不同醫(yī)保制度之間,醫(yī)保門診政策在就醫(yī)管理、籌資方式、待遇水平、支付方式上存在較大差異,呈現(xiàn)"碎片化"現(xiàn)象。結(jié)論乙肝患者直接經(jīng)濟負擔較重,存在醫(yī)療費用結(jié)構(gòu)不合理,抗病毒治療率較低等問題。乙肝患者的醫(yī)療保障水平有限,醫(yī)保政策差異大,缺乏一定的公平性。應(yīng)逐步完善醫(yī)療保障制度頂層設(shè)計,縮小各地醫(yī)保政策差距,逐步將乙肝納入門診保障范圍并提高其待遇水平;同時規(guī)范乙肝診療行為,加強乙肝防治工作,以減輕乙肝患者經(jīng)濟負擔,維護其健康權(quán)益。
[Abstract]:Objective to analyze the direct medical costs of the patients with hepatitis B and its composition, influence factors, to explore the implementation status of hepatitis B patients with medical insurance outpatient policy and existing problems, put forward reasonable measures to reduce the economic burden of hepatitis B patients, provide the basis for the improvement of medical insurance policy. Through the library, Internet, government platform to collect relevant documents in some areas of Jiangsu province outpatient medical insurance policy and management methods, and summarize and organize. Describe the 13 overall planning area of Jiangsu Province, health care workers, outpatient medical insurance policy situation of residents and the new rural cooperative medical insurance, including Medicare outpatient disease specific implementation of hepatitis B patients and security policy (salary payment etc.). Department of infectious disease in Jiangsu 2 grade three hospital infection of hepatitis B patients 50 and 3 grade three hospital clinicians 5 people were interviewed about hepatitis B The average per capita annual outpatient clinic visits and doctors on hepatitis B prevention and treatment guidelines > < the interpretation and application of Jiangsu province were selected. 2 level three hospital in 2014 1~12 months 14910 people outpatient hepatitis B patients and 966 hospitalized patients with hepatitis B as the study sample, obtain patients with direct medical costs and medical information from the hospital medical records system. Describe the clinic and direct medical costs for hospitalized patients with hepatitis B and its components are direct medical costs, annual outpatient costs, Medicare reimbursement fees and reimbursement; the direct medical costs of the patients with hepatitis B, hospitalization days were analyzed by single factor analysis of hospitalized patients with hepatitis B; the direct medical cost of multivariate linear regression analysis. The results of 1. patients with hepatitis B direct medical costs (1) 14910 people in outpatient patients with hepatitis B hepatitis B outpatient cases, 8952 male passengers (60.04%), 5958 female passengers (39.96%); 25~34 years of age Group visits the most (4131 times), accounting for 27.71%, at least 0~14 year old age group (56 people), accounting for 0.38% of Medicare patients; 9940 people (66.67%), the payment of 4970 patient visits (33.33%); in Medicare patients, health care workers were 9830 people (98.89%), residents Medicare patients 110 people (1.11%); patients with antiviral treatment rate was 37.46% and the rate of health care workers in patients treated with antiviral therapy (37.80%) than the residents of Medicare patients (29.09%) total.14910 million outpatient hepatitis B cases direct medical cost was 14188409.81 yuan. The average outpatient cost is 951.60 yuan, of which the highest proportion of drug costs (790.27 yuan), accounting for 83.05%; per capita outpatient visits for 12 years second, per capita outpatient expenditure was 11419.20 yuan; the average outpatient expenses (997.71 yuan) of male was higher than female (882.32 yuan), the difference was statistically significant (P0.05); 30~59 year old age group (980.33 yuan) the highest, the difference was statistically significant (P0.05); health care workers Patients (953.22 yuan) higher than the residents of Medicare patients (811.05 yuan), the difference was statistically significant (P0.05); antiviral therapy patients (1094.77 yuan) was higher than that in patients undergoing antiviral therapy (865.86 yuan), the difference was statistically significant (P0.05); patients with average reimbursement of 62.32%, health care workers (62.51%) higher than that of patients with medical insurance patients (42.76%), the difference was statistically significant (P0.05). (2) hospitalized inpatients with hepatitis B hepatitis B cases in 966 people, male 649 people (67.18%), 317 female passengers (32.82%); 25~34 patients up to age group (339 persons), accounting for 35.09%, 0~14 year old age group (at least 11 passengers), accounting for 1.14% of Medicare patients; 554 people (57.35%), the payment of 412 patient visits (42.65%). In the patients with medical insurance, health care workers were 526 people (94.95%), residents Medicare patients 28 people (5.05%); patients with antiviral treatment rate was 38.61% and the rate of health care workers (39.35% patients treated with antiviral therapy ) than the residents of Medicare patients (32.14%); the average hospitalization time was 24.78 + 16.81 days, up to 15~29 days of hospitalization group (416 persons), accounting for 43.06%, at least for at least 60 days hospitalization group (51 people), accounting for 5.28%; hospitalization days (median) male (21 days) than women (19 days), the difference was statistically significant (P0.05); Medicare patients (24 days) than to pay patients (17 days), the difference was statistically significant (P0.05); employee medical insurance patients (24 days) than residents of Medicare patients (22.5 days), the difference was statistically significant (P0.05).966 inpatient total direct medical costs of hepatitis B cases 12714108.85 yuan. The average hospitalization cost of 13161.60 yuan, of which the highest proportion of drug costs (9025.09 yuan), accounting for 68.57%; the average hospitalization cost of male was higher than female (13711.37 yuan) ($12036.05), the difference was statistically significant (P0.05); 30 or more days of hospitalization group (18255.02 yuan) higher than other days of hospitalization no group. There was statistical significance between group differences with hospitalization costs (P0.05); Medicare patients (14153.12 yuan) higher than that of patients with fee (11828.35 yuan), the difference was statistically significant (P0.05); patients with severe hepatitis B (17256.20 yuan) the highest, moderate hepatitis B patients (12827.62 yuan) of hepatitis B patients with mild (11628.48 yuan) the lowest. There was statistical significance between the groups of different disease severity, the cost difference (P0.05); antiviral therapy patients (13957.82 yuan) was higher than that in patients undergoing antiviral therapy (12660.78 yuan); the average reimbursement rate for 70.45% patients, health care workers (70.88% patients) than the residents of Medicare patients (60.95%), the difference was statistically significant (P0.05); multiple stepwise regression analysis showed that the degree of serious illness, hospitalization, antiviral treatment, settlement is the influence factors of hospitalization expenses (P0.05).2. outpatient medical insurance policy with hepatitis B status and CO ordinating the various health situation in Jiangsu Province The outpatient policy project name is different, the main chronic disease outpatient and outpatient special disease, serious illness; outpatient disease is great difference in the number of more than dozens of little. Only a few policy in 13 areas of outpatient medical insurance, health care workers in 12 areas will be included in the scope of protection of hepatitis B, Medicare residents only the 5 regions included hepatitis B, NCMS has 9 areas will be included in the scope of hepatitis B disease; around policy types are different, some areas including all HBV related diseases, including some areas only part of hepatitis B virus related diseases, such as cirrhosis, severe hepatitis. Among different regions, between different medical insurance system for the same a region, in the medical management of outpatient medical insurance policy, financing, the level of treatment, there is a big difference between the way of payment, showing the phenomenon of "fragmentation". Conclusion the direct economic burden of hepatitis B patients than Medical costs are heavy, unreasonable structure, low rate of antiviral therapy of hepatitis B patients. The level of medical care, health insurance policy differences, lack of fairness. We should perfect the top-level design of medical security system gradually, reduce the medical insurance policies will be gradually incorporated into the gap, hepatitis B outpatient insurance range and improve its level of treatment; at the same time specification for diagnosis and treatment of hepatitis B, hepatitis B to strengthen prevention and control work, to reduce the economic burden of patients with hepatitis B, safeguard the health rights.

【學位授予單位】：東南大學
【學位級別】：碩士
【學位授予年份】：2017
【分類號】：R512.62;F842.684

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