上海市城市弱势群体医疗保障制度的现状、挑战与对策

城市中的低收入群体以及由于疾病、残疾等原因导致贫困的人群在医疗保障方面往往处于弱势,这部分人群需要更为有效的医疗保障。本文分析了上海市弱势群体的基本医疗保险、医疗救助、补充医疗保险等政策规定;在全面梳理弱势群体医疗保障制度的基础上,分析了保障体系当前在覆盖人群、保障内容、公平性与效率方面所面临的挑战;并提出明确定位、加强制度衔接,建立收入支出相关联的保障对象确定机制,对城镇居民基本医疗保险参保人群予以政策倾斜,保障范围向常见病、慢性病辐射等进一步完善制度体系的策略。     

社会医疗保险与我国医疗服务利用的公平性研究

目的:考察我国社会医疗保险对医疗公平性的影响。方法:利用中国健康与营养调查数据,基于集中指数进行研究。结果:(1)我国医疗服务利用的集中指数为正,但其取值和显著性随时间推移而下降;(2)新型农村合作医疗对集中指数的贡献总体为负,且绝对值呈扩大趋势;(3)城镇居民基本医疗保险和城镇职工基本医疗保险对集中指数的贡献为正,但前者的影响有限。结论:我国医疗服务利用的公平性逐渐改善;社会医疗保险对医疗公平性的影响存在差异,这表现为新型农村合作医疗成为提高公平性的重要社会医疗保障制度,而城镇职工基本医疗保险在较大程度上降低了医疗公平,城镇居民基本医疗保险的影响则相对较小。     

天津市基本医疗保险制度公平性评价

目的:对天津市基本医疗保险制度的公平性进行评价,分析公平性方面存在的问题。方法:从横向和纵向两个方面评价天津市基本医疗保险制度的公平性,横向采用参保、筹资、医疗服务利用公平性等指标评价,纵向分析人口老龄化和现收现付制,以及个人账户对医疗保险公平性的影响。结果:参保机会、城乡居民筹资较公平;不同收入人群间的基金筹集、职工实际筹资负担率、城乡居民医疗服务利用、代际之间以及个人账户方面存在一定的不公平。结论:继续扩大医保覆盖范围,根据收入差异制定不同的缴费额、起付线和封顶线,完善社区卫生服务体系,逐步建立和完善老年护理保险制度,取消退休人员的基本医疗保险个人账户。     

我国基本医疗保险住院服务受益公平性研究

目的:研究我国三种基本医疗保险制度下住院服务受益公平性问题。方法:利用中国家庭动态跟踪调查(CFPS)2010年基线调查数据,运用两部分模型来探讨不同制度下、不同收入水平的参保人群在医保覆盖的住院服务利用率和住院经济补偿两方面是否存在差异。结果:各收入组别在住院服务利用率方面差异不大;而在报销住院费用方面,较高收入组和最高收入组的医保报销费用分别比最低收入组高26.3%和36.5%。具体到每一制度,城镇职工医保不同收入组之间的报销费用不存在显著差异;城镇居民医保参保人员报销费用随收入水平的增加而呈现上升趋势;新农合制度只有最高收入组与最低收入组之间存在一定差异。结论:我国基本医疗保险在住院服务利用率方面不存在明显的不公平特征,但在医保报销水平上存在与收入相关的不公平特征。城镇职工医保的公平程度较高,新农合次之,而城镇居民医保受益公平性最差。从制度间的比较而言,新农合参合人员的住院率和医保报销费用均显著偏低。应积极推进基本医疗保险制度整合,加强医疗救助体系建设,完善大病保险制度,以改善制度公平性。     

城镇居民基本医疗保险对住院服务利用公平性的影响

目的:评价我国城镇居民住院服务利用的公平性,探究城镇居民基本医疗保险对住院服务利用公平性的影响。方法:集中指数标准化和分解方法。结果:2007—2010年,我国城镇居民应住院未住院次数的均值总体上呈下降趋势;该指标的标准化集中指数分别为-0.195、-0.218、-0.160、-0.212,差异在1%水平上显著,说明住院服务利用不公平状况依然存在,穷人更容易出现应住院未住院的情况。个人收入和城镇居民基本医疗保险是促进住院服务利用公平性的两个主要因素。结论:城镇居民基本医疗保险对改善住院服务利用公平性的作用重要但是有限,应综合改革卫生服务的筹资和提供体系,保障居民促进健康和获得医疗的基本权益。     

城乡老龄居民医疗保障公平性比较分析——基于广州的调查

[目的]对城乡老龄人群的医疗保障公平性进行比较,并提出促进对策及建议。[方法]利用调查数据,依经济水平分组,通过比例法、集中指数的计算,对老龄居民医疗保险筹集与偿付、医疗服务需要与利用的公平性进行比较。[结果]在现行不同层次的医疗保险框架下,仍存在少数未被覆盖的老龄群体;针对老龄人群的医疗保险费用偿付是累退的,低收入者的费用负担要相对高于高收入者;在医疗服务的需要与利用方面,同样存在与收入相关的不平等。从门诊与住院的医疗服务利用情况看,现有基本医疗保险制度,更多集中在住院医疗费用的偿付方面,针对老龄人群的门诊医疗服务利用有待改进。[结论]城乡老龄群体医疗保障公平性有所改进,但仍存在不平等现象。政府对老龄群体的医疗保障问题需要给予高度关注,从制度层面给予健康保障。     

6个城区1 053户贫困居民医疗卫生服务需求利用及其影响因素分析

随着国家城市医疗救助制度广泛建立和城镇居民基本医疗保险试点启动,贫困人群作为两种制度双重覆盖的特殊社会群体逐步得到社会各界的关注和重视.开展贫困居民的卫生服务需求调查,分析贫困居民卫生服务利用现状和影响因素,将为城市医疗救助的进一步完善和城镇居民基本医疗保险制度方案设计提供依据.     

社会医疗保险共付制度对居民健康影响

目的 探讨社会医疗保险共付制度对医疗费用的影响和对患者健康状况的影响,为城镇居民基本医疗保险提供政策性建议.方法 利用我国6个省份、13个城市的城镇居民家庭调查数据,采用SPSS 13.0软件进行T检验和Logistic回归分析.结果 自付医疗与公费医疗相比,健康人群医疗费下降了60.6%,非健康人群下降了61.4%.不同共付制度下人均医疗费用差异有统计学意义(P＜0.05),不同的共付比例对健康状况影响差异有统计学意义(P＜0.05).此外,年龄、性别、教育程度、收入对健康状况影响差异均有统计学意义(P＜0.05).结论 共付制度能够有效节约医疗费用,但对居民的健康状况也有明显的负向影响.     

不同基本医疗保险类型对中老年人口健康状况的影响及其变化趋势研究

目的分析不同的基本医疗保险类型对于中老年人健康状况的影响的差异并随着时间变化的趋势。方法基于CHARLS数据2011、2013和2015年3次调查都包括的中老年人样本,采用描述性统计、有序Logistic回归、混合面板数据回归的方法的进行分析。结果在基本生活活动能力(BADL)评分上:城镇居民基本医疗保险与城镇职工基本保险对于BADL评分影响的差异波动较小,而新农合与城镇职工基本医疗保险对于BADL影响的差异呈现逐步缩小的趋势,但仍存在较大差距。在自评健康状况上:城镇居民基本医疗保险与城镇职工基本医疗保险在自评健康状况影响的差异无统计学意义,但是新农合与城镇职工基本医疗保险在自评健康状况影响的差距有进一步拉大的风险。结论基本医疗保险制度在发展完善的同时,居民的健康公平性仍面临着严峻的挑战。逐步整合城乡医疗保险制度,并适时推进与城镇职工基本医疗保险合并,提升基本医疗保障制度的统筹层次,是从制度上缩小不同医疗保险制度健康效果差异行之有效的策略。     

医疗救助在医疗保障体系中的地位和作用

医疗救助是政府对因患病而无经济能力诊治的贫困人群,实施专项帮助和资金资助的一种医疗保障制度。从保障人群的健康权,促进社会稳定,构建和谐社会,提高医疗服务及医疗保险制度公平性的高度出发,论述了建立与发展医疗救助制度的重要意义;分析了我国实施医疗救助的特点以及医疗救助与基本医疗保险的共同点与区别;阐述了医疗救助在医疗保障体系中的地位和作用。     

中老年卫生服务利用不平等研究:三种基本社会医疗保险的作用

目的 了解中国中老年人身体健康状况,分析在三种基本社会医疗保险下卫生服务利用的不平等性.方法 基于中国健康与养老追踪调查2013年数据,采用多元Logistic回归等方法分析拥有不同基本医保的中老年人在身体健康状况和卫生服务利用方面的差异.结果 城镇职工医疗保险、城镇居民医疗保险和新型农村合作医疗保险人员自评健康状况得分分别为2.74分、2.59分和2.49分;慢性病患病率分别为52.07%、55.66%和57.78%;4周患病率分别为12.74%、16.49%和13.92%.相对于城镇职工医疗保险参保人群,新型农村合作医疗参保人群对门诊服务(OR=0.82)和住院服务(OR=0.79)的利用以及城镇居民医疗保险参保人群对门诊服务(OR=0.77)和住院服务(OR=0.69)的利用均处于较低水平;对其中慢性病参保人群进行回归分析其结果相似,以上OR值差异均有统计学意义(P<0.05).结论 不同医保的中老年人在健康状况和卫生服务利用上存在不平等性,应通过统筹发展城乡医保、提高筹资及报销比例来缩小不同医保保障水平的差异.     

经济收入和医疗保健制度对卫生服务公平性的影响

文章应用“利用/需要比“(Le Grand法)对南通和淄博两市职工家庭卫生服务利用的公平性进行分析发现,家庭经济收入对卫生服务公平性影响不大,不同医疗保健制度人群间存在不公平性,自费医疗限制了卫生服务利用,且与宏观经济状况和卫生服务体系改革有密切的关系.建议完善卫生服务体制改革,关注城市自费人群的卫生服务利用,提高卫生服务公平性.     

User fees and health service utilization in Vietnam: how to protect the poor?

OBJECTIVES: Vietnam started its health reform process two decades ago, initiated by economic reform in 1986. Economic reform has rapidly changed the socio-economic environment with the transition from a centrally planned economy to a market-oriented economy. Health reform in Vietnam has been associated with the introduction of user fees, the legalization of private medical practices, and the commercialization of the pharmaceutical industry. This paper presents the user fees and health service utilization in Vietnam during a critical period of economic transition in the 1990s. STUDY DESIGN: The study is based on two national household surveys: the Vietnam Living Standard Survey 1992-1993 and 1997-1998. METHODS: The concentration index and related concentration curve were used to measure differences in health service utilization as indicators of health outcomes of income quintiles, ranking from the poorest to the richest. RESULTS: User fees contribute to health resources and have helped to relieve the financial burden on the Government. However, comparisons of concentration indices for hospital stays and community health centre visits show that user fees can drive people deeper into poverty, widen the gap between the rich and the poor, and increase inequality in health outcomes. CONCLUSIONS: An effective social protection and targeting system is proposed to protect the poor from the impact of user fees, to increase equity and improve the quality of healthcare services. This cannot be done without taking measures to improve the quality of care and promote ethical standards in health care, including the elimination of unofficial payments.     

Enhancing measurement of primary health care indicators using an equity lens: An ethnographic study

Introduction  

One important goal of strengthening and renewal in primary healthcare (PHC) is achieving health equity, particularly for vulnerable populations. There has been a flurry of international activity toward the establishment of indicators relevant to measuring and monitoring PHC. Yet, little attention has been paid to whether current indicators: 1) are sensitive enough to detect inequities in processes or outcomes of care, particularly in relation to the health needs of vulnerable groups or 2) adequately capture the complexity of delivering PHC services across diverse groups. The purpose of this paper is to contribute to the discourse regarding what ought to be considered a PHC indicator and to provide some concrete examples illustrating the need for modification and development of new indicators given the goal of PHC achieving health equity.     

城镇基本医疗保险对恶性肿瘤患者住院治疗及费用的影响分析

目的:恶性肿瘤患者经济负担较重,本研究以郑州市为例,探索不同医疗保险类型对恶性肿瘤治疗及其费用的影响.方法:随机抽取郑州恶性肿瘤医保患者600名,统计分析其住院费用影响因素.结果:医保种类、就诊医疗机构级别、住院日、病种等对次均住院费用有影响;治疗费用结构上,两类保险患者无明显差异,但各分类费用职保患者均较高.结论:职工医疗保险的保障力度较居民医保大,职保患者各类费用整体偏高,但不影响诊疗方案的选择.应加大政府投入,减少卫生服务利用差异,制定符合国情的诊疗规范,通过加大监管力度,改革支付方式等减少道德风险造成的卫生资源浪费.     

威海市农村居民卫生服务公平性研究

目的：根据威海市居民健康状况调查资料，评价不同收入水平农村居民卫生服务公平性。采用Gini系数和Lorenz曲线评价收入分配的公平性；集中指数、集中曲线、利用／需要比等指标描述卫生服务的公平性。结果显示不同收入水平人群健康分布存在不公平；低收入人群卫生服务需要的满足程度仍受到限制。     

整合城乡居民基本医疗保险制度筹资政策分析——基于公平性视角

目的:从公平性角度对新农合与居民医保制度的筹资政策进行分析。方法:收集2008—2015年新农合和居民医保的筹资数据,新农合数据来自于中国卫生统计年鉴(2009—2012),中国卫生和计划生育统计年鉴(2013—2016)和新型农村合作医疗统计信息手册(2008—2015),居民医保数据主要来自中国劳动统计年鉴(2009—2016)和中国社会保险年鉴(2009—2015)。采用了根据支付能力筹资的方式来衡量城乡居民医保筹资的公平性。选择个人缴费占城乡居民人均可支配收入的比例作为比较医保筹资公平性的具体指标。结果:新农合和城镇居民医保筹资机制类似,个人缴费占人均筹资额比例低于1/4。人均筹资额占农村居民人均纯收入和城镇居民人均可支配收入的比例分别低于2%和5%,而个人缴费占农民人均纯收入和城镇居民人均可支配收入的比例低于1%。居民医保和新农合个人缴费占城乡居民人均可支配(纯)收入比例的差距有所扩大。结论:居民医保和新农合个人缴费占人均可支配收入比例低。农村居民和城镇居民医保采取的平等筹资掩盖了城乡居民在医保筹资方面的不公平性。     

Inter-state disparities in health care and financial burden on the poor in India

Over five decades of independence, India has made rapid strides in various sectors. However, its performance in social sectors and particularly the healthcare sector has not been too rosy. Being the State's responsibility the healthcare has traditionally been influenced by individual State's budgetary allocation. Consequently inter-state disparity in availability and utilization of health services and health manpower are distinctly marked. This has implications for achievement of Health for All for the nation as a whole. Keeping in view the significance of studying inter-state variations in healthcare, this study focuses on the performance of healthcare sector in 15 major States in India. This is attempted through a comparative analysis of various parameters depicting availability of health services, their utilization and health outcomes. Our analysis depicts the prevalence of considerable inequity favoring high income group of States. In terms of healthcare resources, for instance, it indicates that the high income States hold a superior position in terms of: per capita government expenditure on medical and public health, total number of hospitals and dispensaries, per capita availability of beds in hospitals and dispensaries and health manpower in rural and urban areas. These parameters of availability have an impact on utilization levels and health outcomes in these States. A comparative profile of high and low income States as well as middle and low income States, both in rural and urban areas, reaffirms a greater financial burden in availing treatment at OPD and inpatient in low income States. In line with the higher financial burden and low per capita health expenditure, the health outcome indicators also depict a disconcerting situation in regard to low income States. These States are marked by lower life expectancy and higher incidence of diseases as well as high mortality rates. In this regard, demand as well as supply side constraints are observed which restrain the optimum utilization of existing health services. Among the low income States the main constraints on the demand side include illiteracy, malnutrition, and lack of infrastructure in accessing the facilities. Certain state specific supply side factors add significantly to under-utilization in low income States. In some of the States, however, corrective actions have been initiated to overcome the problem of the quality and low utilization of health facilities. In due course of time, it is likely that proper implementation of these measures may result in improved utilization level of existing health services, which may be useful to improve health status indicators. Nonetheless, overcoming the current levels of regional disparities in healthcare across three income groups of States may also require additional resources. The latter could be mobilized through assistance of donor agencies and appropriate mix of social and private insurance. Ultimately mitigating the problem of regional disparities in healthcare and protecting the poor and vulnerable from financial burden may require establishing and maintaining proper linkages between socio-economic development and healthcare planning.     

上海郊区居民健康状况和医疗服务利用公平性研究

目的通过对上海郊区合作医疗对象的健康状况与医疗服务利用的分析,评价其健康和医疗服务利用的公平性。方法运用STATA和SPSS统计软件,建立回归模型,并采用集中指数和集中曲线法来评价上海郊区合作医疗对象健康与医疗服务利用的公平性。结果不同收入、年龄、医疗保障制度和地区居民健康状况和医疗服务需要差异显著。不同经济收入人群医疗服务利用存在不公平的现象。门诊服务向高收入人群倾斜,住院服务则偏向于低收入人群。崇明县和奉贤区居民的医疗服务利用低于其他两地区,并且门诊服务利用的不公平程度高于住院服务的利用。结论上海郊区不同收入及地区人群的医疗服务利用存在不公平现象。     

The inverse care law: implications for healthcare of vulnerable populations

Past and present, those with the greatest healthcare needs often receive the least adequate healthcare. This phenomenon, termed the "inverse care law," has implications for healthcare and outcomes for vulnerable populations including low-income persons, racial and ethnic minorities, and the uninsured among others. This article reviews disparities in health status and access to healthcare for vulnerable populations. It illustrates how concentration of risk factors within individuals, families, and communities worsens the paradox between healthcare need and access and highlights the models of healthcare delivery needed to adequately meet the needs of vulnerable populations.