新型农村合作医疗实施后卫生服务可及性和医疗负担的公平性研究

目的:通过对3个新农合试点县879户农民入户调查,研究在实施新型农村合作医疗后,不同收入组参合农民医疗费用负担及受益的公平性。方法:运用集中指数、灾难性卫生支出发生频率等方法,分析不同收入人群卫生服务需要和利用以及医疗费用支出和补偿水平,研究不同收入组受益程度和家庭医药负担的减轻程度。结果:在不同收入人群中,低收入组人群处于“高需要、低利用、高负担、低受益”状况;即两周患病率高,就诊率低,住院费用占家庭收入比例和灾难性卫生支出发生率高,受益比例低。新农合补偿住院费用后,低收入人群家庭负担依然沉重,占全年家庭收入的11.30%。结论:中低和低收入组的卫生服务利用明显低于高收入组;新农合补偿后,相对于补偿前,不公平程度有所缓解,但新农合改善医疗费用不公平的作用是有限的;单靠新农合不足以解决农民大病医药负担和因病致贫问题,对于低收入组这一问题更为突出。     

农村居民收入与医疗服务需求及其弹性研究

目的：了解农民医疗服务需求收入弹性,评价不同收入水平农民用于医疗开支的状况.方法：采用系统抽样方法,对1 228户农民家庭进行健康询问调查,将调查家庭按收入高低分为5组,比较其医疗需求及收入弹性状况.结果：显示需求收入弹性为0.129 2,呈缺乏弹性（〈1）;医疗费用占收入的比重是一个增长的趋势,低收入人群医疗费用支出占收入的比重高于高收入人群.结论：收入虽然对医疗服务需求有一定影响,但农民在收入增加的同时,并不意味着在医疗服务方面花同等比例的钱,对医疗服务的消费并未给予足够的重视.     

低收入农民卫生服务可及性和医疗负担公平性研究

[目的]通过对济南市三县2180户农村居民入户调查,研究新农合制度保障下低收入农村居民医疗卫生服务受益及医疗费用负担的现状。[方法]按照收入水平高低将受访农村居民分为5组,运用集中指数、灾难性卫生支出发生率和差距等方法测量低收入农民卫生需要和利用、医疗费用以及补偿状况,探讨提高低收入人群卫生服务受益水平,降低农民医疗负担的方法。[结果]虽然新农合已接近全覆盖,但保障能力有限。低收入家庭医疗负担沉重,受益水平低,因病致贫,因病返贫问题依然突出。[结论]新农合全覆盖的同时应给予低收入农民更多的政策倾斜。     

1998-2009年山东省人群的山东省个人现金卫生支出研究

目的:研究山东省不同人群的OOP水平,监测卫生筹资公平性。方法:运用比较研究等方法。资料来源于山东省社会经济统计资料。结果:(1)1998—2009年,城镇居民人均OOP占家庭非食品支出的比重从7.39%增加到9.03%,农村居民人均OOP占家庭非食品支出的比重在10%～12%之间;(2)2009年,城镇居民收入最低的10%家庭组其OOP占家庭非食品支出比重最高。结论:(1)城乡居民的医药费用负担水平升高;(2)相对于城镇居民,农村居民的医疗费用负担较重;(3)相对于高收入家庭,城镇低收入家庭居民的医疗费用负担较重。建议:控制居民OOP负担水平;提高政府卫生支出水平,对弱势人群给予重点保护,确保卫生服务的公平、可及。     

山东省居民家庭医疗费用支出占比定量分析

目的了解山东省居民家庭医疗保健费用支出结构,探讨居民家庭医疗费用支出的影响因素。方法基于山东省第五次卫生服务调查数据,利用SPSS对居民家庭卫生费用支出比例进行聚类分析,利用卡方检验对影响居民卫生费用支出的因素进行单因素分析,有序多分类logistic回归进行多因素分析。结果年龄、婚姻状况、文化程度、就业状况、家庭总收入、居住地、是否患慢性病、是否住院和家庭规模对家庭卫生费用支出比例有影响。结论年龄和家庭规模是影响医疗费用支出比例的重要因素,患有慢性病和住院的居民医疗费用支出比例较高;高收入家庭和城镇家庭的医疗费支出比重更低;婚姻状况、文化程度和工作状况影响家庭医疗费支出比例。     

从美国的医疗费支出看医疗保健策略重点

１９８７年美国进行了一次人口基础的纵向调查──全国医疗费支出调查，此项调查收集了从１９８７年１月至１２月３１日的美国平民、非常住美国人口的医疗保健情况，包括医院住院病人、门诊病人以及急诊的医疗支出、医生及其助手的保健服务、处方药剂、医疗装备及运输等，还面询了１４０００家庭约３５０００人有关卫生服务与医疗费情况；牙科费用、无医疗成份的精神卫生服务、行政费用。所有费用以１９８７年医疗保健实际支出校正到１９９３年１２月所需的美元数来表达。结果发现，１９８７年美国人总医疗费支出为５７２０亿美元。按疾病分…     

新型农村合作医疗制度对农村居民医疗负担的影响研究

目的:定量研究新型农村合作医疗制度对农村居民医疗负担的影响。方法:采用基于面板固定效应的倍差法分析中国健康与营养调查的数据。结果:新型农村合作医疗制度显著提升了农村居民的实际报销比例,缓解了高额医疗支出发生,但对农村居民医疗费用及占比影响有限;低收入参合农村居民高额医疗支出风险仍然较大。结论:提高新型农村合作医疗政策深度;加强定点医疗机构的监管;给予低收入农村居民政策倾斜。     

泸水县贫困山区农村居民患病情况及其疾病负担的评价

[目的]调查贫困山区农民的医疗服务需要与利用情况,评价疾病负担程度,探讨导致家庭医疗费用上涨的主要因素。[方法]2007年10月,采用横断面研究方法,入户问卷调查分层随机抽取的泸水县246户1163名山区农民。[结果]山区农村1163名居民的两周患病率、两周就诊率、年住院率分别为21.9%、20.0%、11.7%,均高于2008年第四次国家卫生服务调查的全国农村水平(P﹤0.05)。246个山区家庭年支出医疗费用平均为700元,户主自评最近1年家庭疾病负担重的占48.4%。多重线性回归分析表明,导致家庭医疗费用上涨的主要因素是年住院人次、两周就诊人次。[结论]贫困山区健康需要量较高,"看病难"虽有缓解,"看病贵"仍然突出,应健全基层医疗卫生服务体系,促进基本公共卫生服务均等化,降低医疗费用,提高居民健康水平。     

新农合服务质量满意度及其影响因素调查分析

[目的]为了解新型农村合作医疗（以下简称“新农合”）体制下医疗服务质量,并研究彰响新农合服务质量的主要因素,为完善新农合政策提供依据。[方法]采取典型抽样方法,以参合农民家庭为单位,于山东农村抽取368户家庭为被调查家庭,以该家庭主要成年人为调查对象,收集家庭结构、文化水平、健康水平、健康基本情况、医疗消费和报销比例等数据,并调查不同家庭对新农合服务制度和服务水平的满意度评价。[结果]被调查者对新农合服务、医疗机构的服务质量和报销比例满意度比较低,但是,大部分认为报销能够减轻医疗费用负担。住院并报销医疗费的患者,对新农合制度及其服务的满意度略高于其他人群,基层医院、村卫生室就诊报销比例以及医疗服务质量有待提高。参合农民对新农合服务质量的满意度评价,受人群健康水平、家庭社会经济状况、相对报销比例等因素的影响。[结论]新农合服务对缓解农民就医问题起到了十分积极的作用,但在报销比例、筹资规模和管理方面还存在一些突出问题有待解决。需求与供给的主要矛盾体现在筹资水平低、基层医疗单位提供的卫生服务质量不高、医疗费增长过快和报销水平过低四个方面。因此,探索高效的管理模式、提高管理水平与服务质量、遏制医疗费用上涨迪陕的同时提高报销比例为目前新农合管理的当务之急。     

老龄化与医疗费用支出：基于“临近死亡”效应的分析

目的:分析临近死亡时老龄化与医疗费用支出之间的关系。方法:利用2013年中国健康与养老追踪调查数据,根据退出及死因问卷和普通家庭入户调查问卷设定死亡退出组和存活调查组,探讨不同年龄组人口在死亡前1年以及死亡前1个月在医疗费用支出方面的差异。结果:在未临近死亡时,老年人的医疗费用支出并不会出现大的增加,而实际死亡年龄越高,其平均医疗费用支出反而越低。结论:如果不考虑临近死亡效应,仅仅从年龄角度来讨论人口老龄化与医疗费用的联系,将会高估人口老龄化对于医疗费用的影响。     

农民收入水平及其卫生服务利用研究

为研究农民卫生服务公平性 ,按照收入水平由低到高分为 5组 ,比较 5个收入组农民卫生服务利用、就诊流向和医疗预防保健费用支出等指标。结果表明 ,各组农民住院率、未住院率和未就诊率没有显著性差异 ,低收入组两周就率高 (P<0 .0 5 ) ;就诊流向上 ,89.1%的门诊病人主要集中在村卫生室和乡卫生院 ,5 2 %的住院病人集中在县乡级医院。低收入者乡卫生院门诊就诊比例较高 ,县乡级医院住院利用较高 ,差异有显著性 (P<0 .0 5 ) ;各组年人均医疗预防保健支出没有显著差异 ,但最低收入组年人均医疗费用占收入的 19.6 % ,面临较重的疾病经济负担     

2092例住院终止妊娠孕妇口腔保健意识及行为调查

目的:了解妊娠妇女口腔保健意识及行为,为完善门诊孕妇的口腔保健内容提供依据。方法:对2 092例妊娠妇女入院时进行问卷调查。结果:孕前半年内进行口腔检查保健的孕妇共452例,占21.6%,其中高学历、高收入人群明显高于低学历、低收入人群。1 554例孕妇孕期进行口腔健康状况检查,其中早孕孕妇占17.9%,中孕孕妇占53.7%,晚孕孕妇占28.4%,高学历、高收入孕妇早孕检查率明显高于其他组。孕期出现刷牙出血、对冷热不适、牙疼等孕妇有1 381例(66.0%),其中孕前半年进行口腔保健的孕妇发生率为22.8%(103/452),明显低于孕前半年未进行口腔保健的孕妇。1 677例孕妇孕期接受了口腔保健知识,其中58.2%(976/1 677)的知识主要来源于医务人员。结论:孕前半年及孕早期进行口腔健康保健意义更明显,高学历、高收入人群更注重孕期口腔健康。     

The poor pay more: Health-related inequality in Thailand

This paper examines the equality of utilization for equal need and equity of out-of-pocket expenditure for health services in a large urban area in Thailand. Data from a household health interview survey were used to explore patterns of perceived morbidity, utilization of various treatment sources, and out-of-pocket payment. Financial access to health care, as reflected in medical benefit/insurance cover, appeared to influence reported illness and hospitalization rates. Gross lack of access to health care amongst lower socio-economic groups was not the main problem in this densely populated urban area because people could choose and use alternative health services according to their ability and willingness to pay. The corollary, however, was an inequitable pattern of out-of-pocket health expenditure by income quintile and per capita. The underprivileged were more likely to pay out of their own pocket for their health problems, and to pay out of proportion to their household income when compared with more privileged groups. Furthermore, the underprivileged were least likely to be covered by government health benefit schemes, in contrast in particular to civil servants, who paid less out of pocket and did not contribute to their medical benefit fund. The private health sector (private clinics and private hospitals) was the major provider of health care to urban dwellers for both outpatient and inpatient services. Policy options for the short and long term to improve the equity of payment systems for health care are discussed.     

Association between obesity and medical care expenditure among Taiwanese adults

The aim of this study is to evaluate the relationships between obesity and medical care expenditure among Taiwanese adults and to assess the influence of sex, age and socioeconomic status. Our study sample consisted of 12,250 adults aged 18 years or older from the 2001 National Health Interview Survey (NHIS), who had consented to the linking of their survey responses with their NHI claims records. Obesity was defined by Body Mass Index based on the WHO-Asia Pacific categories. Adjusted expenditure for obese class II and class I men were, respectively, 44.6% (95%CI: 27.1%-68.7%) and 39.5% (95%CI: 39.4%-41.2%) greater than normal weight men. For obese class II and class I women, the adjusted expenditure were, respectively, 93.3% (95%CI: 69.9%-114.6%) and 56.1% (95%CI: 50.4%-61.4%) greater than normal weight women. After adjusting for other factors, higher medical care expenditure was associated with a higher BMI for each age group. The relative magnitude of the association became more apparent as age increased. Annual medical care expenditure increased as the BMI increased among women, which was particularly apparent among low socioeconomic status women. On the other hand, the relationship between BMI and medical care expenditure in men varied by household income. In conclusion, there is a strong positive relationship between higher BMI and increased medical care expenditure and this varies according to sex, age and socioeconomic status. Our findings suggest that projections of future health care costs attributable to obesity will need to take into consideration the demographic make-up of the obese population.     

Ability to pay and impoverishment among women who give birth at a University Hospital in Kathmandu,Nepal

Abstract

Pregnant women giving birth in Nepal need to use out-of-pocket payment for delivery care services due to a lack of insurance policies. The objective of this study was to examine the ability of pregnant Nepalese women to pay for delivery care services and the effects of the current household health expenditure on impoverishment due to hospital-based delivery services, especially normal delivery (ND) and caesarean section (CS). A cross-sectional study was conducted from May to August 2009 at Tribhuvan University Teaching Hospital. Ability to pay was defined as the current health spending being less than 5% of annual household income. Poverty occurred when a household's per capita income fell to less than US$1 per day. Impoverishment was considered as poverty headcount and normalised poverty gap. On average, the percentage of annual household income spent on current delivery care was 5.9% in the ND group and 9.7% in the CS group. The CS group had a stronger impoverishment effect resulting in a high per cent change of payment-induced poverty headcount by 78.1% and poverty gap by 97.3% compared to 7.7 and 24.1% in the ND group, respectively. There is a strong need to develop a well-prepared financial system to prevent the issue of poverty and impoverishment.     

Inequality in the face of death? Public expenditure on health care for different socioeconomic groups in the last year of life

OBJECTIVE: To investigate the association between public expenditure on health care in the last year of life and individual socioeconomic status in Sweden. METHODS: Population-based study of public expenditure using linked registers for all 16,617 deaths among Stockholm County Council residents in 2002 (population 1.8 million). Age-standardized, total and per capita spend were calculated by income categories, age and specialty. Multivariate analysis examined the association between socioeconomic status and public expenditure. RESULTS: County council expenditure on health care in the last year of life rose with increasing income of the deceased person. Median per capita expenditure increased from 55,417 Swedish Kronor (SEK) (US$ 7542) in the lowest income group to SEK 94,678 (US$ 12,887) in the highest. Total age-standardized spend increased by 60% across the same interval (80,227 [95% confidence interval (CI) 79,946-80,497] to SEK 127,344 [95% CI 126,969-127,719]). Expenditure decreased with increasing age over 65 years in all income groups. Higher income was independently associated with greater total public health spend in multivariate analysis, adjusting for age, sex, health-care utilization and major diagnostic groups. CONCLUSIONS: There is inequality in public expenditure on health care at the end of life across socioeconomic groups in Stockholm. This phenomenon merits attention within Sweden, and beyond, in countries with less comprehensive welfare systems.     

1999—2007年我国城乡居民卫生保健筹资的趋势比较分析与启示

采用1999-2007年数据对我国城乡居民卫生费用筹资水平、结构及个人医疗保健支出的变化趋势进行比较分析。结果：城乡卫生费用筹资总额所占百分比与人口比例逐年呈现“倒置”现象,农村居民人均卫生费用维持在城镇居民的1／3左右;城镇居民人均医疗保健支出保持为农村居民的3-4倍,二者占人均卫生费用的比重均呈上涨趋势;城乡居民人均医疗保健支出占人均可支配（纯）收入的比重稳步增长（2007年趋于一致：5．07％）,但健康消费总体绝对值水平仍很低,尤其是农村居民;2003年以来农村居民医疗保健支出收入弹性大于城镇居民,城乡相对差距正逐步缩小。基于以上研究提出：重点增加农村居民收入,提高社会边际医疗保健支出倾向;明确政府在医疗卫生领域的经济和监管责任,控制医疗费用快速上涨;改善医疗卫生服务条件,扩大医疗保障覆盖面,带动城乡居民医疗保健合理消费;重视文化因素的作用,提高全民健康投资意识和自我保健能力。     

Different income information as an indicator for health inequality among Japanese adults

BACKGROUND: There are several alternative indicators of income information, which is a fundamental measure of individual socioeconomic position. In this study, we compared the degrees of associations of four types of income information with health variables among Japanese adults. METHODS: Using a nationally representative sample of 29,446 men and 32,917 women aged 20 years and over, the associations between four income indicators and health variables were examined using the odds ratio in logistic regression analysis and the concentration index by sex and age group (20-59 years and 60+ years). Income indicators consisted of total household income, equivalent household income, total household expenditure, and equivalent household expenditure. Current smoking and self-rated health statuses were used as health variables. RESULTS: A low income was associated with a high prevalence of smoking and fair/poor self-rated health, with some differences among sex and age groups and income indicators, but less difference among methods of statistical analyses. Total and equivalent incomes were similarly and more markedly associated with smoking and self-rated health statuses, whereas equivalent expenditure showed the smallest degree of health difference. For the population aged 60+ years, the degree of health differences in smoking was similar between income and expenditure. CONCLUSIONS: Although the degree of income-related health differences is dependent on health outcome and both sex and age group, this study suggests that either crude or equivalent household income is a useful indicator for health inequality among Japanese adults.     

Equity and access to health care for pregnant women in Campinas (SP), Brazil]

OBJECTIVE: To compare the health care received during pregnancy, delivery, and the puerperium by women belonging to two different per capita family income strata: less than 1 minimum wage, and 1 or more minimum wages. METHOD: This is a cross-sectional observational study that was carried out with a random sample of 248 female residents of the city of Campinas, in the state of S?o Paulo, Brasil, who had given birth between April 2001 and March 2002. Sociodemographic data, as well as information concerning maternal morbidity and health care during pregnancy, delivery, and the puerperium, were obtained through home interviews. The Kessner index, the Adequacy of Prenatal Care Utilization index, and an index proposed by the authors based on the recommendations of the Brazilian Department of Health were used to assess the adequacy of prenatal care. The minimum wage in Brazil at the time of the study was 180 reais (approximately 71.4 USD). RESULTS: The lower income group included a larger proportion of women with low schooling, as well as adolescents, black women, and single women. Prenatal care was provided by the public Unified Health System to 73.7% of the women in the lower income group, versus 33.3% in the higher income group. The women in the lower income group started attending prenatal care later and had fewer visits in all than higher-income women. However, some health care quality indicators, such as performance of routine laboratory tests and anti-HIV antibody testing, the proportion of cesarean sections, and the frequency of infant rooming-in, showed more favorable figures in the lower income group. Both groups received comparable counseling and had similar rates of clinical testing, post-delivery tubal sterilization, low birthweight children, and premature delivery. Although a significantly higher number of women in the higher income group received optimal prenatal care, the percentage of cases of inadequate care in the lower-income group was still relatively low. The frequency of health problems during pregnancy did not differ significantly between groups, except for anemia and vaginal hemorrhage, which were more frequent among women in the lower-income group (P < 0.001 and P = 0.033, respectively). CONCLUSIONS: Despite marked socio-demographic differences between women in the two income categories, resulting in different living conditions, there were no significant differences between groups in terms of health problems during pregnancy or the quality of the prenatal care received. These results suggest that the organization of public health services in Campinas has succeeded in promoting equity in health care, at least to a certain extent.     

我国单病种收费制与DRGs相关情况述评

1980—2008年,我国卫生总费用从143.2亿元增长到了14 535.4亿元,28年增长了100倍。医院人均门诊和住院费用平均每年增长13%和11%,远高于人均收入的增长幅度。国外的经验表明,不合理的医疗支付制度,是导致卫生费用快速增长的重要原因之一。为了规范医院行为,减轻患者负担,我国政府正在积极对医疗支付制度进行改革。文章通过文献综述的方式,探讨我国单病种付费制度和诊断相关分组的预付制度(DRGs-PPS)的相关研究进展,阐述单病种和诊断相关分组(DRGs)的产生和发展,通过比较分析,提出一种更适合我国的医疗支付方式。