A study of where mentally disordered people receive medical care in Fukuoka Prefecture

OBJECTIVE: To investigate the "secondary medical regions" where mentally disordered people receive out-patient and in-patient medical care in Fukuoka prefecture, and examine factors related receiving care in medical facilities outside of their secondary medical region of residence. METHODS: 16,129 out-patients on June 30, 2001 using "the public assistance system of outpatients' medical expenses" in line with the Law on Mental Health and Welfare for People with Mental Disorders were analyzed. 7513 in-patients with mental disorders in hospitals were also analyzed utilizing data from the "Patient Survey" by the Ministry of Health and Welfare in 1999. Whether they received out-patient care and in-patient medical care in their own region of residence or not was clarified for all of 13 secondary medical regions. Univariate and multivariate analyses with the multiple logistic regression model were employed to evaluate the relationship between the medical care outside their residential region and characteristics, such as the secondary medical region, gender, age, diagnosis, medical care insurance and so on. RESULTS: With out-patient care, patients in secondary medical regions with a small population size tended to receive care outside of their residential region. Other characteristics associated with a significantly an increased proportion receiving care outside of their region included; young age, receiving care in clinics, and medical care insurance as "public corporation staff mutual aid association" and "employees' insurance or government's managed health insurance". For in-patients care, patients in secondary medical regions with a small number of psychiatric beds per population showed a marked tendency to receive care outside of their residential region. A slight correlation was observed between population ant the proportion receiving care outside of their region. Young and diagnoses such as of "mental and behavioural disorders due to use of alcohol," "other mental or behavioural disorders" "neurotic, stress-related and somatoform disorders" or "mood [affective] disorders", were other characteristics associated with an increased proportion receiving care outside of their region. CONCLUSIONS: With the societal prejudice against mental disorders and regional differences in psychiatric medical facilities, it is of interest that this study indicated that mental disordered people receive medical care in a wide and relatively close area beyond their secondary medical region of residence.     

河南省中老年居民门诊治疗费用及就医选择调查

目的 对河南省3个市县中老年人口在门诊治疗时医疗保险的使用情况以及对于医疗费用的影响进行分析,并探讨影响目标人群选择三级医院就诊的因素。方法 于2013年8月对河南省3个市县45岁以上的人群进行问卷调查。结果 共有1 464名被调查者参与了此次调查,在调查前1年的时间里,有1 134名（77.5%）被调查者接受过门诊治疗,其中609名（53.7%）居民门诊治疗次数超过3次。门诊治疗总费用和净费用中位数分别为800元和600元。教育程度、就诊医院类型、是否有慢性病和门诊治疗次数与门诊治疗总费用和净费用的支出都有关联,而医疗保险的使用对医疗总费用和净费用均不产生影响。婚姻状况、在企业工作、平均个人收入、是否有慢性病、离家最近的医院类型在一定程度上会影响人们的就医行为。结论 需要进一步对我国的医疗保险制度进行改革,尽快建立有效的双向转诊机制。     

基于两部模型的家庭医生签约对社区居民医疗费用影响的实证分析

目的：分析家庭医生签约对于社区居民自付医疗费用的影响,探讨签约对缓解居民医疗费用负担的成效。方法：2019年7—9月在厦门、杭州、上海、北京分别选择两个社区卫生服务中心所在街道的居民,根据调研时最新的家庭医生签约率,采用多阶段整群随机抽样的方法获取样本1 508人。医疗费用以基层医疗卫生机构次均就诊费用、次均住院费用以及年医疗总费用（均为自付）为指标,采用两部模型分析家庭医生签约对医疗费用的影响。结果：签约家庭医生的社区居民相较于未签约居民医疗服务利用率（尤其是基层医疗机构服务利用率）显著提高,但是没有显著影响次均就诊费用和年医疗总费用;降低了住院服务利用率,并且次均住院费用减少了673元。结论：家庭医生可以促使基层首诊、分级诊疗格局的形成,但是其作为医疗费用守门人的职责还需进一步加强。这需要进一步提升基层医疗机构和家庭医生服务能力,加强团队间的协作,完善与上级医疗机构或者专科医生的合作机制,突出医疗保险的杠杆作用。     

慢性乙型肝炎病毒感染者医疗服务利用与费用分析

目的　了解慢性乙型肝炎、肝炎后肝硬化和肝癌患者的医疗服务利用情况及费用构成。方法　调查了上海市自费和享有社会医疗保险的 1395例患者 ,门诊和住院的利用情况及详细费用 ,并分析其医疗费用构成和年直接医疗费用。结果　在门诊和住院利用方面 ,自费组和社会医保组差异无显著意义 ;在医疗费用方面 ,社会医疗保险组比自费组增加了 30 %～ 5 0 % ;门诊费用构成分析发现 ,药品费用达 80 %以上 ,检查化验费达 15 %以上 ;分析住院费用构成 ,两组的药品费皆占总费用的 4 5 %～ 6 0 % ,检查化验费为 15 %～ 2 5 %。结论　社会医疗保险减轻了患者个人的经济负担 ,但显著增加了治疗费用。控制医疗费用的增长关键是控制乙肝向肝硬化转化及控制住院药品费用和检查化验费的不合理增长。     

Impact of a national medical fee schedule revision on the cessation of physician home visits among older patients in Tokyo: A retrospective study

As Japan's population continues to age rapidly, the national government has implemented several measures to improve the efficiency of healthcare services and to control rising medical expenses for older patients. One such measure was the revision of the medical fee schedule for physician home visits in April 2014, in which eligibility for these visits was restricted to patients who are unable to visit outpatient clinics without assistance. Through an investigation of patients who were receiving physician home visits in Tokyo, this study examines whether this fee schedule revision resulted in an increase in patients who transitioned from home visits to outpatient care. In a retrospective analysis of health insurance claims data, we examined 80,914 Tokyo residents aged 75 years or older who had received at least one physician home visit between January and May 2014. The study period was divided into four periods (January–February, February–March, March–April, and April–May), and we examined the number of patients receiving home visits in the index month of each period who subsequently transitioned to outpatient care in the following month. Potential factors associated with this transition to outpatient care were examined using a generalised estimating equation. The March–April period that included the fee schedule revision was significantly associated with a higher number of patients who transitioned from home visits in the index month to outpatient care in the following month (odds ratio: 4.46, p < 0.001) than the other periods. In addition, patients receiving home visits at residential facilities were more likely to transition to outpatient care (odds ratio: 10.40, p < 0.001). These findings indicate that the fee schedule revision resulted in an increase in patients who ceased physician home visits and began visiting outpatient clinics for treatment.     

Primary health care in an academic medical center.

In 1975-76 a one-year longitudinal study of the delivery of primary care services was carried out at all ambulatory institutional facilities in Durham County, North Carolina and in 47 of 50 community private practices covering the broad fields of surgery (including urology and orthopedics), medicine, pediatrics, and ob/gyn. The present paper focuses on the private and public clinics of Duke University Medical Center. Data were analyzed to document differentials in sociodemographic characteristics of patients attending these two systems of care. Results showed that patients attending the private clinics are predominantly white and covered by private insurance, while patients attending the public clinics are predominantly black and heavily dependent on Medicaid coverage. The potentially detrimental effects of a two-class system of care on the health of patients, as well as on the education of students, is discussed in the context of a scant medical literature on this subject.     

2005-2012年医保患者住院医疗费用结构分析

目的探讨医保患者住院医疗费用结构变动的原因,为实现医疗费用的有效控制提供参考依据。方法采用几何均数、结构变动度、结构变动值和结构变动贡献率等指标对某医院2005—2012年医保患者住院费用进行统计分析。结果 2005—2012年医保患者平均住院费用呈逐年上升趋势,高于本地区农村居民人均纯收入的增长速度;8年间医院住院费用结构变动度为18.68%,年均结构变动度为2.67%;8年间西药费、化验费、检查费是导致住院费用结构变动上升的主要费用项目,三者的累积贡献率为42.67%;反映医护人员技术劳动价值的费用如诊疗费、护理费、手术费等变动不明显或呈负向变动。结论完善医疗保险支付方式和医疗机构市场监督机制,确定合理的医疗技术服务价格,改变医院的收入结构,控制医疗费用的快速上涨。     

Economic evaluation of disability prevention programs for community-dwelling elderly secular trend analyses of medical and care expenses comparing participants and non-participants in the programs

OBJECTIVE: This study was conducted to evaluate disability prevention programs for community-dwelling elderly in terms of the cost/benefit balance. METHODS: Out of all residents aged 65 years and over who lived in Yoita Town, Niigata Prefecture, Japan (n = 1,673), 1,544 persons participated in the baseline survey conducted in November, 2000 (response rate, 92.2%). Based on the results, Yoita town then launched several kinds of disability prevention programs for community-dwelling elderly, e.g., preventive programs for falls, dementia and homeboundness. The subjects for the present study included only those aged 70 years and over who responded to the baseline survey and were alive as of March 2004. During 2001 to 2003, 146 persons had participated at lease once in one of disability prevention programs (denoted as the participant group), whereas 846 persons had not participated in any of the programs (denoted as the non-participant group). We compared medical and care expenses (sum of national and employment health insurance benefits, and long-term care insurance) between the two groups during 2000-2003, and determined whether participating in program affected subsequent medical and care expenses independent of key confounders [sex, age, and baseline medical and care expenses or health indicator (TMIG-Index of Competence or Generic Mobility Index)], using general linear models. RESULTS: The mean medical expenses per capita and per month slightly decreased over the period of the study in the participant group (51,606 yen for 2000 to 47,539 yen for 2003), while those in non-participant group steadily increased (41,888 yen, to 51,558 yen, respectively). During the same period, the mean care cost per capita and per month increased in both groups, but the increase was much more moderate in the participating group (507 yen to 5,186 yen vs. 8,127 yen to 27,072 yen for non-participant group). Summed cost reduction through the program participation accounted for 49 million yen during the three years (2001-2003). After adjustment for sex, age and baseline medical and care expenses or health indicator, it was estimated as 12 million yen per year. Given that the expenses for the disability prevention programs summed 2.3 million yen per year, the net benefit of disability prevention programs was estimated to be approx. 10 million yen per year. CONCLUSION: Disability preventive programs for the community-dwelling elderly are economically efficient in terms of the cost/benefit balance. Future research is needed to examine how such programs lead to cost reduction.     

武汉市肺结核患者直接医疗费用及其影响因素

  目的  通过对2011-2018年武汉市1.7万例肺结核患者直接医疗费用及其影响因素分析,研究肺结核患者疾病医疗负担,为结核病患者相关保障政策优化提供依据。  方法  对125万条医保结算信息使用秩和检验,对住院、门诊直接医疗费用分组分析;使用多元线性回归和广义线性估计模型,对患者单次住院及年费用进行多因素分析。  结果  次均门诊、次均住院、年人均直接医疗费用依次为147.51元、8 849.57元、9 607.01元,次均门诊报销比6.36%,住院报销比为67.56%。患者性别、年龄、医保类型、医院级别、是否进行手术、是否使用中药及就医发生年份为直接医疗费用的主要影响因素（均有P < 0.01）。  结论  现有肺结核患者住院医疗费用在可负担范围内,贫困结核患者疾病负担较重,结核治疗周期长,门诊保障不足,亟待出台有针对性的门诊报销统筹政策。     

贵州省肺结核病医疗保障现状调查分析

目的 调查贵州省结核病（TB）定点医院肺结核诊疗费用在不同医疗保障政策中的报销情况,为贵州省进一步完善TB医疗保障政策提供依据。方法 采用统一设计的调查表,对贵州省97家TB定点医院2020年肺结核诊疗费用在四种不同医疗保障政策中的报销情况进行调查,分析起付线、报销比例、封顶额等。结果 全省97家TB定点医院,门诊实施单病种包干政策的比例为38.14%（37/97）;在城镇居民基本医疗保险(URBMI)、新型农村合作医疗保险（UCMS）、城乡居民基本医疗保险（城乡居）和城镇职工基本医疗保险(UEBMI)四种医疗保障政策中,门诊报销比例依次为92.86%（26/28）、100%（28/28）、81.16%（56/69）、36.08%（35/97）;门诊报销比例中位数依次为50%（P25:50%,P75:57.50%）、55%（P25:50%,P75:100%）、75%（P25:45%,P75:100%）、0（P25:0,P75:72.50%）;URBMI、UCMS、城乡居住院报销比例的中位数均为80%（P25:75%,P75:80%）,UEBMI为85%（P25:80%,P75:90%）。医疗救助覆盖率为50.56%。结论 贵州省目前的医疗保险体系对TB的医疗费用保障水平相对有限,基本医疗保障政策对肺结核门诊诊疗费用报销覆盖面较窄,报销比例和封顶额相对较低,肺结核患者的经济负担仍较重,建议将TB纳入门诊统筹病种,切实提高TB患者医疗保障水平。     

丙型肝炎创新药医保准入支付政策对医药费用的影响研究

目的:分析天津和成都两地丙肝创新药医保准入支付政策对人均医药费用产生的影响,探究两地政策效果的差异及原因。方法:收集天津市2014年5月—2018年10月某定点医院的全部丙肝患者病历记录,以及成都市2016年1月—2019年6月医保数据。采用中断时间序列对政策实施前后人均医药费用的变化进行评估。结果:创新药准入支付政策实施后,天津人均医药总费用水平瞬时下降了7 753.43元,其中人均药费下降了5 718.34元,人均其他诊疗费用下降了2 035.09元(P0.01)。成都人均医药总费用水平瞬时上升了6 680.78元(P0.01),其中人均药费上升了6 917.20元(P0.01),人均其他诊疗费用长期趋势每月下降318.88元(P0.01)。结论:创新药医保政策的实施效果受到多个因素的影响,医保准入谈判极大降低了创新药费用,按人头付费政策的实施降低了其他诊疗费用。建议:应积极推进创新药国家准入谈判;在入围创新药支付标准全国统一的情况下,地方医保部门应积极推进实施门诊慢性病患者医药费用按人头支付或基于价值/疗效支付,进一步降低其他诊疗费用;因地制宜制定并落实创新药配套政策。     

DRG改革中医保机构的诉求对其行为的影响研究

目的：对DRG改革中医保机构的诉求和行为进行调查,并分析其诉求对行为的影响。方法：通过问卷调查,对医保机构在DRG下的诉求和行为进行因子分析,分别提取了诉求和行为的公因子,通过线性回归,分析了诉求对行为的影响。结果：DRG改革下,医保机构的诉求包括促进医疗机构服务能力提升、医保机构经办能力提升、医保机构的医疗评估能力提升、医保机构的监管能力提升四个方面。医保机构的行为集中于调整DRG政策、开展监督考核、与医方协商三个方面。医保机构的诉求侧重点决定了医保机构行为的重点方向。结论：DRG改革下,医保机构的诉求和行为跟既往有所不同。通过了解医保机构重点诉求来判断其行为的重点方向,对于把握当地改革方向有着很好的预测作用。     

新疆某医院不同医保老年住院患者费用分析

目的 通过比较新疆某三级医院职工医保与居民医保老年人住院费用及报销水平的差别，发现存在的问题，为进一步完善医保相关政策提供建议。方法 选取两种医保住院老年人为研究对象，对其住院及医保报销费用数据进行分析，比较不同医保老年人住院费用及其医保报销的差别。结果 两种医保老年人的住院疾病都以慢性病为主，次均住院天数、住院费用、医保统筹基金报销，个人负担等具有显著性差异。结论 老年人住院费用高，医院应从住院天数、药品费用方面重点监控；医保部门应重点监管医保药品目录外药品的使用，在报销政策上要考虑年龄因素的影响，适当提高老年人慢病的门诊可报费用标准；提高居民医保的报销水平，以减轻居民医保老年人的经济负担。     

Use of clinic versus private family planning care by low-income women: access, cost, and patient satisfaction.

Use of private physicians versus public family planning facilities by poverty level and near poverty level women was examined by means of a sample survey conducted in low-income areas of Los Angeles County. Utilization differed by race/ethnicity, with Hispanics more likely to go to federally subsidized family planning clinics (primarily county-run), Whites and Blacks to private physicians. Private family planning offers easier access, greater convenience, and higher satisfaction, albeit at almost double the cost. Clinic usage is influenced by lack of a regular source of medical care and lack of insurance coverage more than poverty level per se. Clinic patients report greater patient education regarding contraceptive methods, but less general medical care during clinic visits. They are more likely than private patients to express a desire for a different source of family planning care.     

医疗服务支付方式的比较和运用

在整个医疗保险体系中,作为医疗保险费用管理和控制的关键环节,如何选择适当的医疗费用支付方式是一个重要内容。文章首先介绍了医疗服务的支付方式,并对各种支付方式优劣进行了比较,最后对各国卫生服务系统支付方式发展和运用进行了探讨,从而为我国的医疗保险制度改革提供参考。     

医疗和养老保险与高龄失能老人长期照料支出——基于CLHLS数据的实证分析

我国尚未建立全国性的长期护理保险制度,老年人的长期照料费用主要由家庭承担,老年人拥有的医疗和养老保障是否影响其长期照料服务利用尚不清楚。利用2011年中国老年健康长寿调查(CLHLS)数据,构建两部模型,分析医疗与养老保险对我国城乡高龄失能老人长期照料支出的影响。研究结果表明,我国城镇高龄老人的长期照料支出显著高于农村高龄老人。公费医疗保险、新农合和养老保险对高龄老人长期照料支出有显著影响,且存在城乡差异。城镇高龄老人享有的医疗和养老保险既影响长期照料支出发生与否,又影响长期照料支出的多寡;农村高龄老人享有的医疗和养老保险仅对其是否发生长期照料支出有影响,对支出数量的影响不显著。建议通过加大医疗和养老保障强度,建立长期护理保险制度,减轻高龄老人家庭长期照料经济负担。     

参保慢性疾病患者医疗费用负担情况调查研究

目的：研究参保慢性疾病患者医疗费用负担情况,探索控制慢性疾病参保患者医疗费用的方法。方法：通过分层整群随机抽样的方法抽取天津中医药大学第一附属医院400名参保慢性病人,对其进行慢性疾病及费用负担情况的问卷调查。结果：参保慢性疾病患者普遍感觉医疗费用负担较重,医疗保险能起到一定的补偿作用,但满意度一般。结论：发挥医疗保险制度的引导作用,进行以社区为重点的慢性病防治管理。     

不同医疗卫生机构的基本医疗保险支付方式选择模式探究

基于不同基本医疗保险支付方式的利弊分析、借鉴国外典型国家基本医疗保险支付方式,结合国内医疗卫生机构基本医疗保险支付方式的成功经验,探究不同医疗卫生机构的基本医疗保险支付方式选择模式。建议针对基层医疗卫生服务机构,采用总额预付制或按人头付费为主的方式;针对二级、三级综合医院,采用总额预付制为基础的,按病种付费为主,结合按人头付费、按服务项目付费和按床日付费等支付方式的医保支付模式;专科医院,采用总额控制下按病种付费和按床日付费相结合的支付模式。