我国农村居民灾难性卫生支出的制度成因分析

目的：中国农村人口的健康问题与中国社会的可持续发展密切相关。我国农村仍存在因病致贫、因病返贫现象。利用灾难性卫生支出率和致贫率作为测量工具,来衡量新型农村合作医疗的保障力度。方法：数据来源于第四次卫生服务调查,采用WHO推荐的方法计算灾难性卫生支出。结果：农村人口的灾难性卫生支出发生率为14.4%,致贫率为9.2%,且两者与地区经济水平呈负相关,最为贫困的西部灾难性卫生支出发生率及致贫率最高,分别为15.8%和10.8%;有住院病人的农村家庭发生灾难性卫生支出和致贫的风险最大。结论与建议：中国农村灾难性卫生支出发生率较高是受多种因素共同影响的结果。其中,新农合制度的保障水平不高,缺乏遏制医疗费用快速上涨有效机制,特别是现存以服务项目付费为主导的支付方式,是导致农村灾难性卫生支出发生率较高的主要制度成因。因此,应以完善新型农村合作医疗的制度设计为重点,加大政府对医疗机构的投入,强化各种配套制度和机制的安排。     

农村贫困家庭灾难性卫生支出风险及影响因素研究——基于2018年CHARLS数据

灾难性卫生支出是衡量健康公平性的重要指标。本文基于2018年中国健康与养老追踪调查数据(CHARLS),采用Logit、Tobit模型分别对农村贫困家庭的灾难性卫生支出发生率、发生强度进行分析。研究结果表明:我国农村贫困家庭灾难性卫生支出发生率为28.20%,平均强度为0.076,因病致贫率为32.40%。家庭规模较小、有65岁以上老人、被访者无工作、有慢性病患者、残疾人的农村贫困家庭灾难性卫生支出风险显著更高;而家庭人均收入、是否有5岁以下儿童,被访者的受教育水平、居民医保的人均保障水平对贫困家庭的灾难性卫生支出无显著影响。因此,本文建议以灾难性卫生支出风险为标准建立医疗费用支出型救助制度,帮助农村贫困家庭摆脱因病致贫、因病返贫的困境。     

城乡居民医保整合对农村家庭灾难性卫生支出的影响研究

目的：评估城乡居民医保整合对改善农村家庭灾难性卫生支出的作用,有针对性的提出城乡居民医保整合的优化策略。方法：基于中国家庭追踪调查（CFPS）2010-2018年5期追踪数据,采用双重差分倾向得分匹配模型检验城乡居民医保整合对农村家庭灾难性卫生支出的影响。结果：城乡居民医保整合显著降低了农村家庭灾难性卫生支出的发生率,健康水平、人力资本支出、家庭资产积累是重要的作用渠道。结论：建议持续推进城乡居民医保整合、因地制宜制定医保统筹政策、将灾难性卫生支出纳入农村居民返贫致贫监测预警指标体系。     

山东省农村家庭灾难性卫生支出及其影响因素

目的了解山东省农村地区家庭灾难性卫生支出状况及其相关影响因素,为政策制定提供依据。方法于2014年3—4月,利用世界卫生组织推荐的算法计算灾难性卫生支出,分析不同特征家庭灾难性卫生支出情况,采用二元logistic回归分析灾难性卫生支出的影响因素。结果山东省农村家庭灾难性卫生支出发生率为19.73%,致贫率为9.54%。多因素分析显示:家庭成员中有老年人(OR=1.443,95%CI=1.273～1.631)、5岁儿童(OR=1.639,95%CI=1.135～2.439)、慢性病人(OR=2.285,95%CI=1.935～2.516)的家庭其发生灾难性卫生支出的比例较高;多种不利因素的组合增加了灾难性卫生支出发生的风险;对卫生保健服务的需求和利用、人口学因素均是灾难性卫生支出的影响因素。结论建议决策者今后通过扩大医疗保险项目的覆盖范围、发展补充医疗和大病保险,增强居民保健意识等,减轻居民现金卫生支出。     

建档立卡贫困人口医疗保障政策效果研究——基于改善灾难性卫生支出的视角

[目的]基于改善灾难性卫生支出的视角,对建档立卡贫困人口的医疗保障政策效果进行分析。[方法]利用焦作市2018年"建档立卡贫困人口托底救助数据",设置医疗保障政策的保障水平和医疗保障政策对灾难性卫生支出发生率的降低程度两项评估指标,评估医疗保障政策对建档立卡贫困人口的实施效果。[结果]在40%的阈值下,基本医保保障水平为51.56%,基本医保补偿使灾难性卫生支出发生率下降了7.8‰,下降幅度为63.93%;托底救助使保障水平提升了30.87%,托底救助使灾难性卫生支出发生率下降了1.2‰,下降幅度为48.58%。[结论]基本医保补偿降低了建档立卡贫困户的灾难性卫生支出发生率,尤其对于改善医疗费用较高家庭的灾难性卫生支出效果更好;托底救助使大多数家庭实现了避免发生灾难性卫生支出的目标。该政策对于因病致贫患者灾难性卫生支出改善的效果优于因残致贫,体现了托底救助政策的精准性。     

贫困农村地区高血压及其合并症病人家庭灾难性卫生支出分析

目的对贫困农村地区高血压及其合并症患者家庭灾难性卫生支出进行分析,评价新型农村合作医疗(简称新农合)对降低家庭疾病经济风险所起到的作用,为政府控制这类慢性病的经济负担提供政策建议。方法采取面对面的问卷调查方式收集高血压及其合并症患者家庭的卫生支出和费用报销资料,计算灾难性卫生支出和家庭因病致贫情况。结果研究发现,高血压及其合并症具有很强的家庭致贫作用,因高血压及其合并症导致家庭灾难性卫生支出发生率为22.2%,经过新农合制度的费用补偿,灾难性卫生支出发生率下降到19.2%。结论贫困农村高血压及其合并症患者家庭灾难性卫生支出发生率较高,但新农合对缓解这类疾病导致的家庭灾难性卫生支出作用有限,政府应该采取更加有效的措施降低该类疾病的经济负担。     

灾难性卫生支出的城乡差异及分配敏感性研究

目的:分析实现全民医保后我国灾难性卫生支出的发展趋势、城乡差异及分配敏感性状况。方法:利用中国家庭动态跟踪调查2012年与2014年数据,采用世界卫生组织关于灾难性卫生支出及分配敏感性计算的方法。结果:2012—2014年,灾难性卫生支出总体发生率和发生强度均有明显下降。总体而言,灾难性卫生支出的收入分配状况相对均等。但是,发生率绝对值较高,且城乡有别,农村受到的灾难性卫生支出冲击更大;穷富有别,灾难性卫生支出更多发生在穷人身上。2012年城市发生率比农村更不均等,2014年正好相反。2012—2014年,所有家庭平均差距的集中指数由负变正。结论:全民医保对于降低灾难性卫生支出发生率与发生强度有一定作用;有限的保障内容、水平可能导致医保无法改善甚至加剧灾难性卫生支出的强度;收入水平与医疗保险差异导致农村、穷人遭受更大的灾难性卫生支出发生风险。     

新农合贫困和低收入居民灾难性卫生支出研究——基于三省份的抽样调查

目的：分析农村居民灾难性卫生支出情况以及新农合缓解灾难性卫生支出的能力。方法：2011年分别选取浙江、湖北、重庆作为样本地区,通过现场调查获取问卷1 661份,计算参合家庭的年自付医疗卫生费用、灾难性卫生支出发生率、平均差距和相对差距和集中指数。结果：补偿前后,贫困家庭的灾难性卫生支出发生率、平均差距、相对差距均最高,低收入组次之。补偿后,集中指数降低,灾难性卫生支出进一步向经济困难家庭集中。结论：通过推进农村大病医疗保险、完善医疗救助制度、实施支付方式改革和完善新农合配套措施等方式,帮助农村贫困和低收入居民抵御灾难性卫生支出。     

云南省农村居民4种慢性病患病情况及对家庭经济影响

目的分析云南省农村居民高血压、糖尿病、冠心病和脑卒中4种慢性病流行现状及对家庭经济影响。方法 2015年1—9月,采用多阶段分层随机抽样方法抽取云南地区农村3 909户家庭进行调查,采用家庭灾难性卫生支出和因病致贫评价4种慢性病对家庭经济影响。结果当地农民4种慢性病导致总的家庭灾难性卫生支出发生率和因病致贫率分别为30.5%(460/1 510)和25.2%(380/1 510),其中因高血压、糖尿病、冠心病和脑卒中导致的家庭灾难性卫生支出发生率分别为25.4%(258/1 015)、39.4%(87/221)、39.8%(76/191)和47.0%(39/83);导致的因病致贫发生率分别为19.8%(201/1 015)、35.7%(79/221)、34%(65/191)和42.2%(35/83)。患有高血压、糖尿病、冠心病、脑卒中、人均收入和年龄均是家庭灾难性卫生支出和因病致贫的影响因素,多因素logistic回归分析结果显示,患高血压、糖尿病、冠心病和脑卒中的患者家庭发生家庭灾难性卫生支出的风险分别是非患病家庭的3.5、3.1、6.2和9.9倍,患高血压、糖尿病、冠心病和脑卒中的患者家庭发生因病致贫的风险分别是非患病家庭的3.8、2.4、4.8和7.2倍,有老年人的家庭也更易出现家庭灾难性卫生支出和因病致贫,其发生风险分别是没有老年人家庭的1.9和1.5倍。较高的人均收入是家庭灾难性卫生支出和因病致贫的保护性因素。结论高血压、糖尿病、冠心病和脑卒中对云南省农村家庭经济的影响巨大。     

基本医疗保障制度对于改善灾难性卫生支出效果评价

目的了解在基本医疗保险补偿后对于家庭卫生支出的变化,探讨发生家庭灾难性卫生支出(CHE)的概率及其发生的影响因素。方法利用国社科项目课题组2014年在中国八地的实证调查的数据,以灾难性卫生支出发生率、平均差距和相对差距为测量指标,并采用logistic模型分析发生灾难性卫生支出的影响因素。结果北京、辽宁、山东三地在医保报销后CHE发生率下降幅度最大,分别为4.87%、2.078%、1.71%;在平均差距指标上,陕西、山西、北京下降最明显,分别为7.25%、5.79%、2.88%;在相对差距上,陕西、山西、天津最明显,分别为92.44%、74.25%、56.17%;医保种类、家庭年收入和医保实际报销水平是灾难性医疗发生的影响因素。结论基本医疗保险在减少灾难性卫生支出起到了积极的作用。     

Factors affecting catastrophic health expenditure and impoverishment from medical expenses in China: policy implications of universal health insurance

Objective

To assess the degree to which the Chinese people are protected from catastrophic household expenditure and impoverishment from medical expenses and to explore the health system and structural factors influencing the first of these outcomes.

Methods

Data were derived from the Fourth National Health Service Survey. An analysis of catastrophic health expenditure and impoverishment from medical expenses was undertaken with a sample of 55 556 households of different characteristics and located in rural and urban settings in different parts of the country. Logistic regression was used to identify the determinants of catastrophic health expenditure.

Findings

The rate of catastrophic health expenditure was 13.0%; that of impoverishment was 7.5%. Rates of catastrophic health expenditure were higher among households having members who were hospitalized, elderly, or chronically ill, as well as in households in rural or poorer regions. A combination of adverse factors increased the risk of catastrophic health expenditure. Families enrolled in the urban employee or resident insurance schemes had lower rates of catastrophic health expenditure than those enrolled in the new rural corporative scheme. The need for and use of health care, demographics, type of benefit package and type of provider payment method were the determinants of catastrophic health expenditure.

Conclusion

Although China has greatly expanded health insurance coverage, financial protection remains insufficient. Policy-makers should focus on designing improved insurance plans by expanding the benefit package, redesigning cost sharing arrangements and provider payment methods and developing more effective expenditure control strategies.     

大病保险对我国中老年人家庭灾难性卫生支出影响实证分析

目的:考察大病保险对我国中老年人家庭灾难性卫生支出的影响,为完善我国大病保险制度提供建议。方法:以中国健康与养老追踪调查数据库(2011年与2015年)中45岁及以上的城乡中老年人家庭作为研究对象,利用描述性统计法和两部模型法分析大病保险对我国中老年人家庭灾难性卫生支出的影响。结果:目前的大病保险政策从总体上降低了中老年人家庭灾难性卫生支出的发生率,但没有显著降低其发生强度。结论:目前的大病保险并未达到其预期的效果,只是解决了"面"的问题,从总体上降低了灾难性卫生支出发生的可能性,但并没有解决"点"的问题,没有有效降低其大额的医疗卫生支出进而减少其医疗经济负担。建议各地各级政府相关部门应进一步完善大病保险制度,从而真正有效减轻居民重大疾病医疗经济负担。     

Insured yet vulnerable: out-of-pocket payments and India's poor

Protecting households from high out-of-pocket (OOP) payments for health care is an important health system goal. High OOP payments can push households into poverty and make them vulnerable to catastrophic health expenditures. This study, based in India, aims to: (a) estimate OOP payments for health and related impoverishment across economic groups; (b) decompose OOP payments and relate the contribution of their components to impoverishment; and (c) examine how well recently introduced national insurance schemes meant for the poor are able to provide financial protection. The analysis of nationally representative data from India shows that 3.5% of the population fall below the poverty line and 5% households suffer catastrophic health expenditures. The poverty deepening impact of OOP payments was at a maximum in people below the poverty line in comparison with those above (Rs. 10.45 vs. Rs. 1.50, respectively). Medicines constitute the main share (72%) of total OOP payments. This share reaches 82% for outpatient care, compared with 42% for inpatient care. Removing OOP payments for inpatient care leads to a negligible fall in the poverty headcount ratio and poverty gap. However, if OOP payments for either medicines or outpatient care are removed then only 0.5% people fall into poverty due to spending on health. These findings suggest that insurance schemes which cover only hospital expenses, like those being rolled out nationally in India, will fail to adequately protect the poor against impoverishment due to spending on health. Further, issues related to identifying the poor and their targeting also constrain the scheme's impact. A broader coverage of benefits, to include medicines and outpatient care for the poor and near poor (i.e. those just above the poverty line), is necessary to achieve significant protection from impoverishment.     

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.     

新农合患者大病医疗救助水平分析——以湖北省A地和贵州省B地为例

目的:分析A、B两地大病医疗救助情况,为提高大病医疗救助水平和保障效果提出可行性建议。方法:选取湖北省A地和贵州省B地,2013年通过现场调查获取问卷872份,分析大病医疗救助受益患者的概况,计算救助前后年度自付费用以及灾难性卫生支出发生率、相对差距。结果:大病医疗救助对患者经济负担缓解作用有限;目前大病医疗救助政策救助比偏低,救助范围较窄,非五保、低保大病患者救助起付线高且年救助封顶线低,导致实际救助比远低于政策救助比。结论:逐步拓宽大病患者合规费用救助范围并提高救助比;做好大病医疗救助与大病医疗保险、基本医疗保险的有效衔接;将大病门诊自付费用纳入大病医疗救助范围。     

精准帮扶视域下灾难性卫生支出的脆弱群体分析*

目的：识别脆弱群体,降低灾难性卫生支出发生风险。方法：采用2018年《中国健康与养老追踪调查》数据。 用卡方检验比较不同组别之间灾难性卫生支出发生率,用logistic回归分析识别灾难性卫生支出的影响因素。结果：2018年, 家庭灾难性卫生支出总体的发生率为27.37%。logistic回归分析结果显示,已婚、自评健康差、家庭规模小、家庭经济情况差、有家庭成员利用门诊或住院卫生服务、家庭有慢性病患者、家庭有60岁以上成员的家庭为灾难性卫生支出的脆弱群体。 结论：鉴于灾难性卫生支出发生率较高,需采用更加精准有效的策略来降低居民的灾难性卫生支出发生风险。     

Evaluating the financial protection of patients with chronic disease by health insurance in rural China

Background  

A growing number of developing countries are developing health insurance schemes that aim to protect households, particularly the poor, from financial catastrophe and impoverishment caused by unaffordable medical care. This paper investigates the extent to which patients suffering from chronic disease in rural China face catastrophic expenditure on healthcare, and how far the New Co-operative Medical Insurance Scheme (NCMS) offers them financial protection against this.