【摘要】：[目的]通過分析湖北省典型地區(qū)城鄉(xiāng)全部參保居民（職工醫(yī)療保險、居民醫(yī)療保險和新農合）十四種重大疾病住院醫(yī)療費用，構建測算方法，測算在不同保障范圍以及政策建議補償水平下，居民基本醫(yī)療保險保障特殊病種重大疾病所需資金量和重大疾病補充商業(yè)保險所需籌資的基數，討論資金籌集與重大疾病保障體系構建的關系以及目前重大疾病保險政策的合理性，繼而提出更有針對性的重大疾病保障籌資管理和體系構建的政策建議。 [方法]在文獻研究的基礎上，通過回顧性數據調查法，獲取湖北省A城市2009年1月-2011年5月基本醫(yī)療保險（職工醫(yī)療保險、居民醫(yī)療保險和新農合）所有參保居民的基本信息、病種名稱、住院費用及醫(yī)保統籌費用等數據。在A城市選取2家具有重大疾病規(guī)范治療水平的醫(yī)療機構，調查得到部分病種2009年1月-2011年5月醫(yī)院病案管理信息系統中治療費用和具體治療方式信息。運用統計學分析法、反事實分析法、敏感度分析法、規(guī)范分析法等方法對所收集的數據和信息進行分析。 [結果]1.重大疾病治療手段和費用特征：重大疾病需要手術、放療、化療、綜合治療等多種治療方法，進行手術治療的平均住院費用要高于其他治療方式的平均總住院費用，但手術治療的病例百分比相對較低（17.7%）。 2．重大疾病患者住院總費用分布與構成：（1）重大疾病患者住院總費用呈偏態(tài)分布，平均住院費用9401.09元，77.5%的住院病人費用在10000元以內；（2）腦梗死、肺癌和胃癌占重大疾病病種住院總費用構成前三位；（3）在新農合住院總費用構成中，藥品費和治療費所占比例最高，分別為48.0%和19.3%，目錄外藥品占22.7%。 3.重大疾病人年住院費用分析：（1）重大疾病人年平均住院費用為13223.30元，人年住院費用在10000元以下的占69.0%；（2）與湖北省新增重大疾病醫(yī)藥費用限額標準相比，雖然限額能覆蓋大部分手術病例的費用，但至少25%的惡性腫瘤患者人年費用超過病種限額。同時手術等特殊治療方式的病例比例較低。 4.重大疾病服務利用與就醫(yī)流向分析：（1）重大疾病平均年住院人次占該地平均年住院人次的4.7%，住院人次隨著醫(yī)療機構級別的升高而增加，新農合3級醫(yī)療機構的住院人次比例最低（62.2%），城鎮(zhèn)職工基本醫(yī)療保險最高（82.4%）；（2）重大疾病市外住院人次占住院總人次比例為21.3%，其中新型農村合作醫(yī)療市外就醫(yī)比例最低（19.6%），職工醫(yī)療保險市外就醫(yī)比例最高（25.9%）。 5.重大疾病基本醫(yī)療保險補償情況：（1）重大疾病的實際補償比為52.3%，其中新農合的實際補償比最低（35.5%），城鎮(zhèn)職工補償比最高（70.5%）；（2）新農合實際報銷比例在3級醫(yī)療機構僅31.3%；相比城鎮(zhèn)職工在3級機構報銷比例70.5%；（3）市外住院報銷比例為44.3%，市內為59.3%。新農合重大疾病市外住院實際報銷比例最低（20.5%）；城鎮(zhèn)職工市外住院補償比例最高（66.8%）。 6.十四種重大疾病保險測算：（1）經測算可得當地農村重大疾病醫(yī)療保險達到政策建議水平(70%)需增加基本醫(yī)療保險資金341.11萬元，人均4.74元;城市需282.93萬元，人均8.08元。新農合所需資金增量占當地2010年年度籌資總額的3.5%，占支出總額的4.4%。（2）按標準對新農合部分病種手術治療等過程實施保障，測算得到資金的增加量為127.81萬元。 7.新農合重大疾病籌資-補償比敏感度分析：隨著農村十四種重大疾病病種的保障水平的提高，補償比每升高1%，基本醫(yī)保所需要資金相對需要增加0.10%-0.11%。 8.補充商業(yè)醫(yī)療保險籌資基數測算：對城鄉(xiāng)居民重大疾病基本醫(yī)療保險補償后個人負擔費用按標準分段賠付，不受病種限制，重大疾病商業(yè)補償保險的籌資基數為928.65萬元，，人均8.68元。 [結論]1如果僅對手術等的特殊治療方式進行補償，可能會導致大部分其他治療方式的高費用重大疾病患者得不到保障，降低了資金的使用效率。 2對A城市十四種重大疾病全過程治療方式的保障水平提高到70%是可行的。 3重大疾病患者的醫(yī)療機構利用和基本醫(yī)療保險補償存在明顯的城鄉(xiāng)差異，應優(yōu)先對農村重大疾病進行保障。 4補充商業(yè)保險的人均籌資基數8.68元占全省指導性籌資標準34.7%。表明指導籌資標準理論上可以滿足重大疾病保障的資金需求。 5各地區(qū)應對重大疾病保險費用進行測算，根據自身經濟水平與管理能力，建立適宜當地社會發(fā)展水平的重大疾病醫(yī)療保障制度。
[Abstract]:[Objective] by analyzing the hospitalization expenses of fourteen major diseases in the urban and rural areas of Hubei Province, all the residents (medical insurance, medical insurance and nncms) were built, and the calculation method was constructed to calculate the basic medical insurance for the major diseases of special diseases under the different scope of guarantee and the compensation level of policy recommendations. Gold and major diseases supplement the base of financing for commercial insurance, discuss the relationship between fund raising and the construction of major disease guarantee system, and the rationality of the current insurance policy for major diseases, and then put forward more targeted suggestions for the management and construction of major disease guarantee fund management and system construction.
[Methods] on the basis of literature research, through the retrospective data survey method, the basic information of all the residents of the basic medical insurance (staff medical insurance, resident medical insurance and nncms) in A city of Hubei province January 2009 -2011 year, the name of disease species, the cost of hospitalization and the overall cost of medical insurance were obtained. In the city of A, 2 furniture were selected. The medical institutions of the standard treatment level of major diseases were investigated for the treatment cost and specific treatment information in the hospital medical records management information system in May -2011 year January 2009. The data and information were analyzed by means of statistical analysis, anti fact analysis, sensitivity analysis, and normative analysis.
[results]]1. major disease treatment means and cost characteristics: major diseases require surgery, radiotherapy, chemotherapy, comprehensive treatment and so on. The average cost of hospitalization for surgical treatment is higher than the average total hospitalization expenses of other treatments, but the percentage of surgical treatment is relatively low (17.7%).
The total cost distribution and composition of 2. patients with major diseases were as follows: (1) the total cost of hospitalization was partial distribution, the average hospitalization cost was 9401.09 yuan, and the cost of hospitalized patients in 77.5% was less than 10000 yuan; (2) cerebral infarction, lung cancer and gastric cancer accounted for the first three in the total cost of hospitalization for major diseases; (3) the total cost of hospitalization in NCMS. The highest proportion of drug fees and treatment fees was 48% and 19.3% respectively, and the drugs outside the list accounted for 22.7%.
3. analysis of the cost of hospitalization for the year of major diseases: (1) the average annual hospitalization cost of major diseases was 13223.30 yuan, and the annual hospitalization cost of the person was less than 10000 yuan. (2) compared with the medical cost limit standard of major new diseases in Hubei Province, although the limit could cover the cost of the cases of the major breakup, at least 25% of the malignant tumor patients were in the human year. The cost exceeds the limit of disease and the proportion of cases with special treatment such as surgery is low.
4. the analysis of service utilization and medical treatment flow of major diseases: (1) the average annual hospitalizations of major diseases accounted for 4.7% of the average annual inpatient number, the number of inpatients increased with the level of medical institutions, the ratio of the number of inpatients in the new NCMS 3 level medical institutions was the lowest (62.2%), the basic medical insurance of urban workers (82.4%); (2) major diseases. The proportion of inpatients outside the city is 21.3%, of which the proportion of the new rural cooperative medical service is the lowest (19.6%), and the proportion of medical insurance for workers and workers outside the city is the highest (25.9%).
5. the basic medical insurance compensation of major diseases: (1) the actual compensation ratio of major diseases is 52.3%, of which the actual compensation ratio of nncms is the lowest (35.5%), the compensation ratio of urban workers is the highest (70.5%); (2) the actual reimbursement ratio of the NCMS is only 31.3% in the 3 level medical institutions; compared with the urban workers in the 3 level institution reimbursement ratio 70.5%; (3) out of the city hospital. The proportion of reimbursement was 44.3%, and the actual rate of reimbursement in the city outside the city was the lowest (20.5%) for 59.3%. NCMS, and the proportion of urban workers and workers outside the city was the highest (66.8%).
6. insurance estimates for fourteen major diseases: (1) it is estimated that the level of medical insurance for major diseases in the rural areas can be reached to the level of policy recommendations (70%) to increase basic medical insurance funds by 3 million 411 thousand and 100 yuan and 4.74 yuan per capita; the city needs 2 million 829 thousand and 300 yuan and 8.08 yuan per person. The capital increase of the NCMS accounts for 3.5% of the annual total annual fund-raising in 2010, accounting for total expenditure. The amount of 4.4%. (2) is guaranteed according to the standard, and the amount of capital increase is 1 million 278 thousand and 100 yuan.
7. new NCMS major disease financing and compensation ratio sensitivity analysis: with the improvement of the level of fourteen major diseases in rural areas, the compensation ratio is 1%, and the required funds for basic medical insurance need to be increased by 0.10%-0.11%.
8. supplement the financing base of commercial medical insurance: the individual burden on the basic medical insurance compensation for the major diseases of urban and rural residents is paid according to the standard subsection, and it is not restricted by the disease. The financing base of the commercial compensation insurance for major diseases is 9 million 286 thousand and 500 yuan and 8.68 yuan per person.
[conclusion if]1 only compensates for special treatment, such as surgery, most of the other treatments may not be guaranteed for the high cost of the disease and reduce the efficiency of the use of funds.
2 it is feasible to increase the level of treatment for fourteen major diseases in A city to 70% in the whole process.
3 there are obvious differences between urban and rural areas in the utilization of medical institutions and the compensation for basic medical insurance in major diseases. Priority should be given to the protection of major diseases in rural areas.
4 the per capita fund-raising base of commercial insurance is 8.68 yuan (34.7%.), which accounts for the province's guiding fund-raising standard, which shows that the fund raising standards can theoretically meet the demand for funds for the guarantee of major diseases.
5 each area should measure the insurance costs of major diseases and establish a medical security system for major diseases suitable for the level of local social development according to its own economic level and management ability.
【學位授予單位】：華中科技大學
【學位級別】：碩士
【學位授予年份】：2013
【分類號】：F842.684

【參考文獻】

相關期刊論文 前10條

1 強舸;唐睿;;反事實分析與公共政策制定——以“自行車難題”為例[J];公共管理學報;2012年03期

2 陳琳,楊寶林,劉玉秀,聶梅梅,易學明;住院醫(yī)療保險患者的醫(yī)療費用分析[J];醫(yī)學研究生學報;2003年10期

3 李志宏;;我國重大疾病保險現狀及未來發(fā)展[J];遼寧經濟;2007年10期

4 別紅寶;張海霞;;開展農村兒童重大疾病醫(yī)療保障工作的實踐與思考[J];江蘇衛(wèi)生保健;2011年04期

5 楊文沁;;國外重大疾病保險介紹[J];金融經濟;2007年12期

6 王靜;呂暉;項莉;羅五金;;醫(yī)療保障制度抵御疾病經濟風險的作用綜述[J];中國衛(wèi)生經濟;2011年06期

7 辛一琪;胡正路;;急性心肌梗死患者住院費用構成及影響因素分析[J];中國衛(wèi)生經濟;2011年08期

8 王娟娟;葉露;胡善聯;郝春鵬;韓鳳;;透析的疾病經濟負擔研究[J];中國衛(wèi)生資源;2006年02期

9 何艷梅;張國標;林輝;;鼻咽癌患者住院費用影響因素分析[J];現代醫(yī)院;2011年07期

10 杜飛進;張怡恬;;中國社會保障制度的公平與效率問題研究[J];學習與探索;2008年01期

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