本文選題：高血壓 + 經(jīng)濟負擔(dān)　； 參考：《山東大學(xué)》2013年博士論文

【摘要】：研究背景 中國是高血壓大國,高血壓平均患病率達到38.6%,發(fā)病人數(shù)已經(jīng)超過2億。高血壓疾病在嚴重影響患者健康狀況的同時,也給患者及其家庭帶來了沉重的經(jīng)濟負擔(dān),由于高血壓病是不能根治的疾病,患者往往需要接受終身治療,因此高血壓病情的變化和伴隨疾病的進展會對醫(yī)療費用產(chǎn)生較大的影響。從高血壓疾病經(jīng)濟負擔(dān)的角度來看,基本醫(yī)療保險制度是降低個人、家庭和社會疾病經(jīng)濟風(fēng)險最直接的手段,它是從經(jīng)濟角度來改善健康行為、提高健康干預(yù)、促進疾病轉(zhuǎn)歸的一種重要的制度安排和經(jīng)濟補償措施,作為一項提高公共健康福利的基礎(chǔ)性政策,其在提高醫(yī)療衛(wèi)生服務(wù)可及性與可承受性,最大程度的降低疾病經(jīng)濟風(fēng)險、發(fā)揮對社會資源的再次分配、促進和維護社會穩(wěn)定和諧等方面具有不可替代的功用。但我們也要清楚的認識到,在我國以基本醫(yī)療保險為主體的醫(yī)療保險體系在補償效果、補償公平性方面還存在一定不足,這些問題需要在制度的建立和完善過程中得到不斷的解決,這也是本研究的現(xiàn)實依據(jù)。 研究目的 通過現(xiàn)場調(diào)查了解高血壓疾病人群在藥品、門診和住院治療中的衛(wèi)生服務(wù)利用情況、疾病費用情況、補償情況等信息,利用疾病負擔(dān)的常規(guī)指標來衡量高血壓疾病對人群造成的經(jīng)濟風(fēng)險。同時比較評價現(xiàn)行的基本醫(yī)療保險制度對人群低于疾病經(jīng)濟風(fēng)險的補償效果、補償公平性及影響因素。在此基礎(chǔ)上,結(jié)合醫(yī)療保障制度由數(shù)量增長向結(jié)構(gòu)調(diào)整的改革趨勢,提出提高基本醫(yī)療保險制度公平性的改進策略,以提高不同醫(yī)保制度之間的橫向公平性,提高城鄉(xiāng)居民尤其是貧困人群對高血壓疾病經(jīng)濟風(fēng)險的抵御能力。 資料來源 定量資料主要來源于現(xiàn)場調(diào)查,本研究采取多階段隨機抽樣的方法,根據(jù)地域分布和社會經(jīng)濟狀況從山東省140個縣區(qū)中隨機抽取4個城市社區(qū)(煙臺福山區(qū)、萊州萊城區(qū)、棗莊薛城區(qū)、德州德城區(qū))和4個農(nóng)村縣區(qū)(威海乳山市、濰坊高密市、泰安寧陽縣、濰坊壽光市)。每個城市區(qū)以隨機整群抽樣的方法抽取3個社區(qū),每個農(nóng)村縣(市)以隨機整群抽樣的方法抽取3個鄉(xiāng)鎮(zhèn),全省共確定12個社區(qū)和12個鄉(xiāng)鎮(zhèn)進行調(diào)查。每縣區(qū)所抽中的社區(qū)和鄉(xiāng)鎮(zhèn)內(nèi)的所有登記的高血壓患者均為此次調(diào)查的調(diào)查對象(包括各街道和村的患者),全省共抽取9054名高血壓患者。調(diào)查內(nèi)容主要包括高血壓患者及家庭的基本情況、疾病狀況、高血壓門診、住院和藥品利用情況等。 研究方法 1文獻復(fù)習(xí)法 用高血壓、成本、負擔(dān)、費用、價格、保險、公平性等主題詞檢索cnki、萬方、維普、Pubmed、EBSCO等中英文文獻數(shù)據(jù)庫,了解高血壓在中國的流行現(xiàn)狀、疾病經(jīng)濟負擔(dān)的研究方法、風(fēng)險管理、健康貧困防治策略等內(nèi)容,同時系統(tǒng)回顧里疾病經(jīng)濟負擔(dān)、醫(yī)療保險公平性等方面的理論和實證研究,了解國內(nèi)外對疾病經(jīng)濟負擔(dān)、疾病經(jīng)濟風(fēng)險度評價、宏觀醫(yī)保制度設(shè)計策略等方面的改革進展等。 2數(shù)據(jù)分析方法 (1)描述性分析。利用計算資料的均數(shù)、標準差、率和構(gòu)成比、頻數(shù)分布描述等方法對本次調(diào)查的社會人口學(xué)特征、疾病流行特征、行為生活方式等方面進行描述。 (2)疾病負擔(dān)分析。對影響高血壓患者經(jīng)濟負擔(dān)的單影響因素主要采用t檢驗、Kruskal-Wallis H檢驗、Mann-Whitney U檢驗；測量災(zāi)難性衛(wèi)生支出的發(fā)生率,并利用災(zāi)難性衛(wèi)生支出的平均差距和相對差距法估計其嚴重程度；收集的醫(yī)療保險補償金額、家庭收入、門診支出、住院支出等信息采用Probit模型、方差分析、卡方檢驗等統(tǒng)計方法進行多因素分析。 (3)醫(yī)療保險補償分析。用率、構(gòu)成比等指標分析不同醫(yī)療保險在門診、住院和高血壓藥品補償方面的補償水平和補償比,同時采用泰爾指數(shù)法測量補償公平性。 (4)衛(wèi)生服務(wù)利用分析。通過門診率、住院率等指標進行描述,同時利用衛(wèi)生服務(wù)利用標準化法、集中指數(shù)法(CI)對公平性進行實證研究,主要分析非經(jīng)濟收入因素對衛(wèi)生服務(wù)利用的影響。 研究結(jié)果 1高血壓負擔(dān) 高血壓患者年高血壓門診支出為570.72元,年住院支出為7162.5元,住院負擔(dān)尤其是農(nóng)村家庭的負擔(dān)程度要高于第四次衛(wèi)生服務(wù)調(diào)查的平均水平。此外,高血壓藥品支出也相對較高,患者年支出金額平均為565.72元。 2災(zāi)難性衛(wèi)生支出 城鄉(xiāng)居民接受高血壓門診或住院治療后,可以對一部分家庭造成家庭災(zāi)難性支出,發(fā)生災(zāi)難性衛(wèi)生支出的概率約在3%-5%之間,從發(fā)生概率來看,門診治療發(fā)生比例最高,從危害程度來看,住院支出影響更大。從經(jīng)濟風(fēng)險度評價來看,低收入家庭所承受經(jīng)濟風(fēng)險較高。 3醫(yī)療保險方面 本次調(diào)查發(fā)現(xiàn),新型農(nóng)村合作醫(yī)療、城鎮(zhèn)職工醫(yī)保、城鎮(zhèn)居民醫(yī)保三大類基本醫(yī)療保險仍是調(diào)查人群的最主要的參保類型,非基本醫(yī)療保險也會對少部分患者家庭的醫(yī)療費用支出產(chǎn)生一定影響。多元回歸統(tǒng)計結(jié)果也顯示,無論是門診方面還是住院方面,醫(yī)療保險均會對實際費用支出和衛(wèi)生服務(wù)利用產(chǎn)生影響。從醫(yī)保基金的使用情況來看,住院補償是基本醫(yī)療保險補償?shù)闹攸c,住院補償金額約占各類醫(yī)保支出總額的49.38%,其次是門診補償,占34.81%,藥品補償?shù)谋壤?5.81%。 4補償效果 醫(yī)療保險因素對高血壓疾病的影響作用主要體現(xiàn)在衛(wèi)生服務(wù)利用數(shù)量和疾病負擔(dān)的改善。從衛(wèi)生利用次數(shù)上來看,利用probit模型發(fā)現(xiàn)非疾病因素,尤其是醫(yī)療保險因素對疾病負擔(dān)產(chǎn)生影響。從負擔(dān)改善情況來看,各種類型醫(yī)療保險對門診、住院和高血壓藥品支出方面的平均補償水平為350.63元,占家庭收入的比重為2.16%。從社會經(jīng)濟角度進行分層比較,醫(yī)療保險因素對低費用支出情況的補償效果較好,此外發(fā)現(xiàn)醫(yī)療保險的補償金額占低收入家庭的比重遠高于其他家庭類型。 5公平性評價 從基金使用內(nèi)部情況看,門診補償公平性要好于住院補償,但均存在高收入人群受益好于低收入人群的情況；不同醫(yī)療保險間也存在不公平現(xiàn)象,泰爾指數(shù)結(jié)果顯示城鎮(zhèn)職工醫(yī)療保險的受益程度最高。 結(jié)論與建議 從結(jié)果來看,高血壓疾病會對患者家庭普遍造成一定的經(jīng)濟損失,部分家庭在門診、住院和藥品支出方面會顯著增加家庭的經(jīng)濟風(fēng)險,產(chǎn)生經(jīng)濟風(fēng)險的原因既與疾病因素有關(guān),也與其他社會經(jīng)濟因素有關(guān)。 從醫(yī)療保險的角度來看,現(xiàn)行制度對特定家庭來說還是具有較大的影響作用,其經(jīng)濟風(fēng)險的分擔(dān)能力對提高衛(wèi)生服務(wù)利用和降低經(jīng)濟負擔(dān)的損失具有較為明顯的作用。但研究結(jié)果也表明,這種風(fēng)險分擔(dān)能力在不同醫(yī)療保險制度間以及不同社會經(jīng)濟背景人群之間是存在較大差距的,這也需要國家通過多種政治和經(jīng)濟改革措施來解決。 政策建議：(1)推進收入分配改革,提高低收入人群的收入水平；(2)逐步提高基本醫(yī)療保險制度的統(tǒng)籌層次,縮減地域性差異和制度性差異；(3)強化醫(yī)療救助作用,重點解決發(fā)生災(zāi)難性衛(wèi)生支出家庭的疾病經(jīng)濟負擔(dān)；(4)加快醫(yī)療保險體制改革,促進衛(wèi)生服務(wù)的需求和利用與社會經(jīng)濟發(fā)展水平相一致；(5)增強基層醫(yī)療衛(wèi)生服務(wù)能力,繼續(xù)加大對公共衛(wèi)生服務(wù)與基本醫(yī)療服務(wù)的投入。
[Abstract]:Research background
China is a big country with hypertension, hypertension prevalence average rate reached 38.6%, the incidence of hypertension disease. More than 200 million people have serious impact on the health status of the patients at the same time, also to the patients and their family brought a heavy economic burden, because hypertension is incurable disease, patients often need lifelong treatment, so the change of the disease and the accompanying hypertension the progression of the disease will have a greater impact on medical expenses. The economic burden of disease from hypertension perspective, the basic medical insurance system is to reduce the personal, family and society means the disease economic risk of the most direct, it is from the economic angle to improve health behavior, improve health intervention, promote disease development as an important institutional arrangements and economic compensation measures, as a basis for improving the public health and welfare policy, in improving the health service accessibility and Bear, the maximum degree of reduction of disease economic risk, use of social resources re allocation has irreplaceable function to promote and maintain social stability and harmony. But we should also clearly recognize that in our country with the basic medical insurance as the main body of the medical insurance system in the aspects of fair compensation and compensation effect. There are still some problems, these problems need to be solved in time to establish and improve the system process, which is the realistic basis of this study.
research objective
Understand the Hypertension Crowd in the drug through field investigation, the utilization of outpatient and inpatient care in health services, disease cost, compensation and other information, the use of conventional indicators to measure the burden of disease of hypertension on the population caused by the economic risk. At the same time compared to evaluate the compensation effect in current basic medical insurance system is lower than that of the disease economic risk the crowd, fairness and influence factors of compensation. On this basis, combined with the medical security system from quantitative growth to the reform trend of structural adjustment, improve the strategy to improve the basic medical insurance system for fairness, in order to improve the horizontal equity between different medical insurance system, improve the urban and rural residents, especially the poor ability to resist hypertension disease economic risk.
Source of information
The quantitative data from the field survey, this research adopts multi stage random sampling method, according to the geographical distribution and socioeconomic status from 140 counties in Shandong province were randomly selected from 4 communities (Yantai City Fushan District, Laizhou Zaozhuang Laicheng District, Xuecheng District, Dezhou City area) and 4 rural counties (Weihai city of Rushan Weifang, Gaomi City, Tai'an, Ningyang County, Weifang Shouguang City). Each city district 3 communities by random sampling method, each rural county (city) in 3 villages and towns cluster random sampling method, the province has identified 12 community and 12 villages and towns were investigated. The investigation object of each district has out of the community and township in all hypertensive patients were registered in the survey (including the streets and villages, a total of 9054 patients) from hypertensive patients. The investigation included hypertensive patients and families. Condition, disease status, hypertension clinic, hospitalization and drug use, etc.
research method
1 literature review
With hypertension, cost, burden, cost, price, insurance, fairness subject retrieval CNKI, Wanfang, VIP, Pubmed, EBSCO in English literature database, understand the epidemic situation of hypertension in Chinese, research methods, the economic burden of disease risk management, the content of health poverty control strategies, and system review the economic burden of disease, theoretical and empirical research on medical insurance fairness and other aspects, understand the economic burden of disease at home and abroad, the disease economic risk assessment, macro strategy and other aspects of the health care system reform progress.
2 method of data analysis
(1) descriptive analysis. We used descriptive statistics, mean, standard deviation, rate and constituent ratio, and frequency distribution to describe the social demographic characteristics, epidemic characteristics, behavior and lifestyle of the survey.
(2) the disease burden of single analysis. Factors affecting the economic burden of patients with hypertension mainly using t test, Kruskal-Wallis H test, Mann-Whitney U test; the incidence of catastrophic health expenditure measurement, and the average gap of catastrophic health expenditure and relative gap method to estimate the severity of medical insurance; the amount of compensation, collection family income, outpatient expenses, hospitalization expenses and other information by using Probit model, variance analysis, chi square test and other statistical methods for multivariate analysis.
(3) the compensation analysis of medical insurance. The compensation level and compensation ratio of different medical insurance in outpatient, hospitalization and hypertension drug compensation were analyzed by using rate, constituent ratio and other indicators. At the same time, Theil index method was used to measure the fairness of compensation.
(4) the analysis of health service utilization. Through outpatient rate, hospitalization rate and other indicators, we used health service standardization method and centralized index method (CI) to do empirical research on fairness, mainly analyzing the impact of non economic income factors on health services utilization.
Research results
1 the burden of hypertension
Patients with hypertension hypertension outpatient expenditure of 570.72 yuan, annual hospitalization expenses for 7162.5 yuan, especially the average hospitalization burden of rural households to burden more than fourth health service investigation. In addition, the hypertension drug expenditure is relatively high, with the average amount of annual expenditure of 565.72 yuan.
2 disastrous health expenditure
Urban and rural residents received hypertension outpatient or inpatient treatment, can cause catastrophic expenditure on the part of the family, the probability of catastrophic health expenditure is about 3%-5%, the probability of occurrence from the point of view, has the highest proportion of outpatient treatment, judging from harm degree, hospitalization expenditure has greater impact. From the economic risk assessment, low income families bear higher economic risk.
3 medical insurance
The survey found that the new rural cooperative medical care, medical insurance for urban workers, the main types of insured medical insurance for urban residents in the three basic medical insurance is the survey, non basic medical insurance will have a certain impact on the family with a small portion of the medical expense. Multiple regression results also show that both the outpatient or hospital, medical insurance will have an impact on actual costs and health care utilization. From the use of the health insurance fund, hospitalization compensation is the focus of the basic medical insurance compensation, accounting for the total amount of compensation in various medical insurance expenditure of 49.38%, followed by outpatient compensation, compensation of drugs accounted for 34.81%, accounted for 15.81%.
4 compensation effect
The role of medical insurance factors of hypertension is mainly reflected by the number and burden of disease in health services improved. By using the frequency from the health point of view, using the probit model to find the non disease factors, especially the medical insurance factors affect disease burden from the burden to improve the situation, various types of medical insurance for outpatient, inpatient and hypertension the average drug expenditure level of compensation for 350.63 yuan, accounting for the proportion of household income is 2.16%. from the point of view of socioeconomic stratification, good compensation effect to lower expenditures for medical insurance, medical insurance compensation in addition proportion of low-income families is far higher than other family types.
5 Fairness Evaluation
From the use of internal funds, outpatient compensation fairness is better than the hospital compensation, but the existence of the high income people benefit from better than the low income crowd; also the unfairness of different medical insurance, the Theil index showed the benefit degree of medical insurance for urban workers is the highest.
Conclusions and suggestions
From the results, hypertension will generally cause certain economic losses to the families of patients, part of the family in the outpatient, hospitalization and drug expenditure will significantly increase family economic risk, the causes of the economic risk and disease factors are also associated with other social and economic factors.
From the perspective of medical insurance, the current system still has great influence on specific families, the economic risk sharing capacity has obvious effect on improving the health service utilization and reduce the economic burden of loss. But the results also indicate that the risk sharing capacity is there is a big gap between the different medical insurance system and different social and economic background of people, it also needs to solve the country through a variety of measures of political and economic reforms.
Policy recommendations: (1) to promote the reform of the income distribution, improve the income level of low income groups; (2) gradually increase the overall level of basic medical insurance system, reduce the differences of regional differences and the system; (3) to strengthen the medical assistance, focused on solving the problem of catastrophic health expenditure (family economic burden of disease; 4) to speed up the reform of medical insurance system, and promote the utilization of health service demand is consistent with the level of social and economic development; (5) to enhance the ability of primary health care services, continue to increase the public health services and basic medical service investment.

【學(xué)位授予單位】：山東大學(xué)
【學(xué)位級別】：博士
【學(xué)位授予年份】：2013
【分類號】：R544.1;F842.684

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