中国农村互助医疗制度的可持续性分析--基于贵州省开阳县的调查

通过对贵州省开阳县农村互助医疗制度试点情况的调查,分别从供给与需求的角度对开阳县互助医疗制度的可持续性进行分析。通过分析发现,开阳县互助医疗模式在我国西部农村地区的实施具有可持续性。在需求方面表现为:筹资水平在农民经济承受能力之内,筹资水平具有公平性;在供给方面表现为:公共支持加强,可信的政策承诺。但是在风险分摊、管理成本、逆选择等几个方面存在着影响制度可持续性的种种隐忧。     

中国农村互助医疗

哈佛大学领导的项目小组在对中国西部农村问题进行了深入的诊断分析和原因分析之后，提出了通过建立农村互助医疗制度来解决中国西部农村基本卫生和因病致贫问题的初步设想。详细描述了农村互助医疗制度的理论基础和基本框架，并且深入探讨了如何通过试点获得可操作性知识和经验及其实施效果。目标是通过农村互助医疗制度的实施，降低农村居民享受基本医疗的成本，提高基本医疗的质量，减缓农村因病致贫的现象。     

冯三镇建立互助医疗制度的探索--一种新型农村合作医疗的管理模式

1建立互助医疗制度的由来 在全面建设小康社会的进程中。西部地区农民“因病致贫、因病返贫”的问题尤为突出。“小病拖、大病扛，重病等着见阎王”的现象较为普遍。为解决农民的基本医疗问题。贵州省贵阳市开阳县冯三镇曾进行过合作医疗试点。原有的试点方案是农民个人集资5．00元。市、县政府对参合的群众每人各补助1．00元。由于集资少．难以满足农民群众对基本医疗服务的需求，     

冯三镇建立新型合作医疗管理模式的探索

1建立互助医疗制度的由来 为解决农民基本医疗问题，贵州省贵阳市开阳县冯三镇曾进行过合作医疗试点。原有的试点方案是农民个人集资5元，市、县政府对参加合作医疗的群众每人各补助1元，由于集资少，难以支付和满足农民群众对基本医疗服务的需求，群众参与率仅达30％左右。由于参合率、抗风险能力低，合作医疗不能继续进行。经卫生部推荐，     

合作医疗是农村居民健康保障制度的主体形式─—新时期合作医疗性质浅析

社会保障制度改革是整个经济体制改革的重要组成部分，建立多层次的社会保障体系是构筑社会主义市场经济体制的重要支柱之一。八届全国人大第四次会议通过的《中华人民共和国国民经济和社会发展“九五”计划和2010年远景目标纲要》要求”加快养老、失业、医疗保险制度改革，初步形成社会保险、社会经济、社会福利、优抚安置和社会互助、个人储蓄积累保障相结合的多层次社会保障制度”，在“逐步建立城镇社会统筹医疗基金与个人医疗帐户相结合的医疗保险制度”的同时，还要“因地制宜地发展和完善不同形式的农村合作医疗保险制度”。这对于深…     

我国儿童医疗保障体系发展现状及对策

儿童大病的巨额医疗费用已经给一些家庭带来了沉重负担,而我国目前的儿童医疗保障体系现状是:只有商业保险一种医疗保险方式和几个大中城市建立了医疗互助制度。为此,针对建立符合当前国情的儿童医疗保障体系提出如下建议:针对农村儿童应加入农村合作医疗,针对城市儿童应建立儿童合作医疗制度,针对贫困、大病儿童应建立儿童医疗救助制度。     

我国农村互助医疗管理中建立村民自我管理小组可行性探讨

农村互助医疗是一种通过建立互助医疗制度来解决我国西部农村基本卫生和因病致贫问题的综合模式。为了充分发挥农民的作用,增强互助医疗的可持续性发展,并为我国新型农村合作医疗管理探索有效的管理组织形式提供参考。根据公共事务治理的自治组织理论进行建立村民自我管理小组可行性的探讨,通过对访谈法获得的资料进行分析,得出结论:在互助医疗中建立村民自我管理小组是十分必要的;应该发挥基层管理者在互助医疗管理中的作用;吸纳妇女参加自我管理小组等。     

村民信任与中国农村互助医疗制度的可持续发展

农村互助医疗是根据目前中国西部农村地区所面临的基本问题，与卫生改革的相关理论如经济理论、管理学理论等，以及国际实践经验相结合，从需求、供给和政府等多方面同时入手而设计的一种试图解决中国农村卫生问题的综合模式。笔者认为，农民信任与否是互助医疗制度成败的关键，它将直接影响参加互助医疗的人数、筹资水平等，进而影响互助医疗制度的可持续发展。     

互助医疗改善卫生服务公平性的效果评价

利用对镇安县铁厂镇农村互助医疗项目试点情况的基线调查和随访调查数据，采用差异中的差异、医疗服务利用的标准化和集中指数等方法分析了农村互助医疗项目对参保农民门诊和住院服务利用率及其公平性的影响。结果显示，农村互助医疗项目的实施提高了门诊服务利用率，降低了住院服务利用率．显著提高了门诊和住院服务利用的公平性。     

新型农村合作医疗制度进展现状、存在问题及对策研究

在“政府引导、费用分担、互助共济、自愿有偿、服务优先、适应市场、因地制宜、保障健康”的原则指导下，分阶段在农村地区试点推行的新型农村合作医疗制度（以下简称“新制度”），是一种“由政府组织、引导、支持，农民自愿参加，个人、集体和政府多方筹资，以大病统筹为主的农民医疗互助共济制度”（《意见》，2003）。     

Adverse selection in a voluntary Rural Mutual Health Care health insurance scheme in China

This study examines adverse selection in a subsidized voluntary health insurance scheme, the Rural Mutual Health Care (RMHC) scheme, in a poor rural area of China. The study was made possible by a unique longitudinal data set: the total sample includes 3492 rural residents from 1020 households. Logistic regression was employed for the data analysis. The results show that although this subsidized scheme achieved a considerable high enrollment rate of 71% of rural residents, adverse selection still exists. In general, individuals with worse health status are more likely to enroll in RMHC than individuals with better health status. Although the household is set as the enrollment unit for the RMHC for the purpose of reducing adverse selection, nearly 1/3 of enrolled households are actually only partially enrolled. Furthermore, we found that adverse selection mainly occurs in partially enrolled households. The non-enrolled individuals in partially enrolled households have the best health status, while the enrolled individuals in partially enrolled households have the worst health status. Pre-RMHC, medical expenditure for enrolled individuals in partially enrolled households was 206.6 yuan per capita per year, which is 1.7 times as much as the pre-RMHC medical expenditure for non-enrolled individuals in partially enrolled households. The study also reveals that the pre-enrolled medical expenditure per capita per year of enrolled individuals was 9.6% higher than the pre-enrolled medical expenditure of all residents, including both enrolled and non-enrolled individuals. In conclusion, although the subsidized RMHC scheme reached a very high enrollment rate and the household is set as the enrollment unit for the purpose of reducing adverse selection, adverse selection still exists, especially within partially enrolled households. Voluntary RMHC will not be financially sustainable if the adverse selection is not fully taken into account.     

质量控制图在农村互助医疗保险项目监测中的应用

以中国农村互助医疗保险项目试点乡铁厂镇的门诊服务利用人次和门诊补偿费用的监测为例，介绍了质量控制图的制作方法以及质量控制图在项目运行监测中的应用，旨在探索我国的医疗保险制度的监测管理方法。     

A method for implementation of nutritional therapy in hospitals

BACKGROUND AND AIMS: Many barriers make implementation of nutritional therapy difficult in hospitals. In this study we investigated whether, a targeted plan made by the staff in different departments could improve nutritional treatment within selected quality goals based on the ESPEN screening guidelines. METHODS: The project was carried out as a continuous quality improvement project. Four different specialities participated in the study with a nutrition team of both doctors, nurses, and a dietician, and included the following methods: (1) Pre-measurement: assessment of quality goals prior to study including the use of screening of nutritional risk (NRS-2002), whether a nutrition plan was made, and monitoring was documented in the records. (2) Intervention: multidisciplinary meeting for the ward staff using a PC-based meeting system for detecting barriers in the department concerning nutrition, elaboration of an action plan and implementation of the plan. (3) Re-measurement: as in (1) based on information from records and patient interviews, and an evaluation based on focus group interview with the staff. Patients who gave informed consent to participate in the study (>14 years) were included consecutively. Mann-Whitney and Kruskal-Wallis test was used for ordinal data, and Pearson chi(2) test for nominative data. P values <0.05 were considered significant. The study was performed in accordance with the Research Ethics Committee. RESULTS: In this study 141/122 patients were included before/after the implementation period with a mean weight loss within the last 3 months of 6.2 and 5.2 kg, respectively. Before the study we found that BMI was not measured. More than half of the patients had a weight loss within the last 3 months, and 40% had a weight loss during hospitalization, and this was not documented in the records. About 75% had a food intake less than normal within the last week, and nearly one-third were at a severe nutritional risk, and only 33% of these had a nutrition plan, and 18% a plan for monitoring. Barriers concerning nutrition included low priority, no focus, no routine or established procedures, and insufficient knowledge, lack of quality and choice of menus, and lack of support from general manager of the hospital. The staff introduced individually targeted procedures including assigning of responsibility, a nutrition record, electronic calculator of energy intake, upgrading of the dieticians and special diets, communication, and educational programs. A great consistency existed between barriers for targeted nutrition effort and ideas for improvement of the quality goals between the different departments. Quality assessment after study showed an overall significant improvement of the selected quality goals. CONCLUSION: The introduction of a new method for implementation of nutritional therapy according to ESPEN screening guidelines seems to improve nutritional therapy in hospitals. The method included assessment of quality goals, identification of barriers and individual targeted plans for each department followed by an evaluation process. The model has to be refined further with relevant clinical endpoints.     

2001～2010年凯里市实施结核病防治规划终期效果评价

[目的]了解结核病防治规划实施情况,总结经验,为制定今后结核病防治实施计划提供依据。[方法]对凯里市2001～2010年结核病防治规划工作进行评估。[结果]2001～2010年累计登记可疑肺结核病人10 213例,平均就诊率为2.18‰,发现6 035例肺结核病人。涂片检查8 325例,阳性2 044例(初治1 638例、复治406例)。治疗6～8月时,初治涂阳病人治愈率为87.12%,复治涂阳病人治愈率为80.84%。[结论]2001～2010年肺结核病人发现率和治愈率均达到规划要求。     

互助医疗与新型农村合作医疗缓解"因病致贫"的效果比较

目的:比较新型农村合作医疗和农村互助医疗2种医疗保障制度在缓解卫生服务利用人群"因病致贫、因病返贫"方面的效果。方法:资料来源于2005年11月对陕西省镇安县高峰镇和铁厂镇的入户调查数据和样本人群医疗服务利用报表数据,贫困测量指标选用贫困发生率、贫困距指数、收入差距比率、森的贫困指数、补偿资金的使用效率和供给率。结果:农村互助医疗制度缓解卫生服务利用人群"因病致贫"的效果好于新型农村合作医疗制度。建议:新型农村合作医疗制度取消门诊个人账户,对住院和门诊服务利用均进行一定程度的补偿。     

JCI标准在医疗影像设备质量控制中的应用

目的分析JCI标准在医疗影像设备质量控制检测的应用价值。方法采用JCI认证标准对75台医用CT进行风险评估,制定预防性维修计划,检测辐射剂量、机械性能、影像质量参数指标,评估实施前后影像质量。结果 75台CT中,5台高风险设备,14台中风险设备,56台低风险设备,分别实施6个月、12个月、24个月的预防性维修计划;辐射剂量指数、机械性能、图像质量等各项合格率均超过85%以上,其中定位光精度、CT值、躁音、层厚偏差、高对比分辨力、低对比分辨力、床定位精度均大于90%;实施后摄影甲级片（56.13%）明显高于实施前。结论以结果为导向的JCI标准在医疗影像设备质量管理中更具前瞻性,有较强的预警作用。     

Non-evidence-based policy: How effective is China's new cooperative medical scheme in reducing medical impoverishment?

In recent years, many lower to middle income countries have looked to insurance as a means to protect their populations from medical impoverishment. In 2003, the Chinese government initiated the New Cooperative Medical System (NCMS), a government-run voluntary insurance program for its rural population. The prevailing model of NCMS combines medical savings accounts with high-deductible catastrophic hospital insurance (MSA/Catastrophic). To assess the effectiveness of this approach in reducing medical impoverishment, we used household survey data from 2006 linked to claims records of health expenditures to simulate the effect of MSA/Catastrophic on reducing the share of individuals falling below the poverty line (headcount), and the amount by which household resources fall short of the poverty line (poverty gap) due to medical expenses. We compared the effects of MSA/Catastrophic to Rural Mutual Health Care (RMHC), an experimental model that provides first dollar coverage for primary care, hospital services and drugs with a similar premium but a lower ceiling. Our results show that RMHC is more effective at reducing medical impoverishment than NCMS. Under the internationally accepted poverty line of US$1.08 per person per day, the MSA/Catastrophic models would reduce the poverty headcount by 3.5–3.9% and the average poverty gap by 11.8–16.4%, compared with reductions of 6.1–6.8% and 15–18.5% under the RMHC model. The primary reason for this is that NCMS does not address a major cause of medical impoverishment: expensive outpatient services for chronic conditions. As such, health policymakers need first to examine the disease profile and health expenditure pattern of a population before they can direct resources to where they will be most effective. As chronic diseases impose a growing share of the burden on the population in developing countries, it is not necessarily true that insurance coverage focusing on expensive hospital care alone is the most effective at providing financial risk protection.     

男男性行为者自杀行为相关危险因素Logistic分析

[目的]了解男男性行为者(MSM)人群自杀行为及相关危险因素。[方法]采用应答者趋动招募抽样法(RDS)对MSM人群进行招募和自填式匿名调查,用非条件Logistic回归分析进行影响自杀行为的危险因素分析。[结果]共调查201人,最近6个月自杀意念、自杀计划、自杀未遂报告率分别为9%、4.5%、3.5%。单因素Logistic回归分析,影响自杀行为的危险因素分别为:自杀意念13个、自杀计划11个、自杀未遂7个。多因素分析,自杀意念主要危险因素是因同性恋被家人训斥、肯定有抑郁症状、BF性伙伴数多、接受过HIV检测、认为同性恋伤害家庭;自杀计划主要危险因素是因同性恋被家人训斥、肯定有抑郁症状、文化程度低;自杀未遂的主要危险因素是经常参加MSM朋友的家庭聚会、因同性恋被家人训斥、文化程度低。[结论]减少社会家庭歧视,针对性开展心理疏导,可降低MSM人群自杀行为发生。