医疗保障制度设计对慢性病防控的影响研究-以新疆生产建设兵团为例

Nowadays, chronic diseases hold the biggest burden of disease in Chinese health care system. But the shortage of health service capacity and unsatisfied implementation of prevention strategies in chronic diseases have posed significant problems. This study aims to analyze the effects of health security models upon the prevention and control of chronic diseases, and explain its working mechanism based on the economic stimulus of health security system to health-care services. This study takes Xinjiang Production and Construction Corps, which is facing the prominent and serious problems of aging population and chronic diseases, as an example, using data provided by its health-care and insurance sections, to systematically compare and analyze the effects of different health security models on patients' outpatient service utilization in chronic diseases. And, the study will carry out further analysis on the interacting between health care suppliers and demanders through investigation, and collect quantitative and qualitative data of behaviors of chronic disease patients and health-care providers. With these analyses, we can understand the effects of health security models on behaviors of health care suppliers and demanders, and furthermore to understand the impact of health security models to the prevention and control of chronic diseases. Through this study, we could explore the suitable model of health insurance system in Xinjiang, to find the proper way for health service provider to provide suitable services, and policy suggestions to improve the health security system with its effect on chronic disease prevention and control could be generated too.

当前，慢性病已经成为中国疾病负担中最沉重的部分，但慢性病防控服务提供不足，慢性病防控策略实施不尽人意。本研究拟从医疗保障对医疗卫生服务提供的经济激励作用出发，验证医疗保障制度设计对慢性病防控的影响，并解释其作用机制。研究将以人口老龄化严重，慢性病问题非常突出的新疆生产建设兵团为例，利用医疗保险部门的数据，系统比较门诊统筹不同模式对慢性病患者服务利用和疾病进程的影响。同时，通过现场调查，收集慢性病患者的就医行为和卫生服务提供者行为及与慢性病防控有关的定量和定性资料，对供需双方行为进行深入分析。理清医疗保障制度设计影响供需双方行为，进而影响慢性病防控效果的作用过程。探索通过医疗保障制度设计，引导卫生服务提供者提供适宜服务的途径，为完善医疗保障制度设计改进慢性病防控策略效果提出政策建议。

当前，慢性病已经成为中国疾病负担中最沉重的部分。近年来的研究证实住院医疗保险提高了慢性病患者住院服务利用，并降低了灾难性自付费用。然而，从慢性病的疾病发展历程看，有效的门诊服务对于控制疾病进程，减缓病情恶化有着重要作用。国内门诊慢性病保险制度陆续建立，其政策效果如何，是社会关注的问题。本研究对此开展政策影响评价的实证研究，试图明确慢性病门诊政策设计对慢性病患者疾病进程有无影响及其机制。.本研究利用新疆某地区2011—2014年城镇职工医疗保险报销数据开展了政策效果的评价研究。采用有对照的间断时间序列研究设计，分析享受门诊慢病政策与未享受门诊慢病政策的高血压并发症患者各1703人在研究期间因单纯性高血压、高血压并发心脏病、高血压并发肾病及高血压并发脑病入院的每季度总住院费用、总住院时长的水平及趋势变化，发现门诊特殊慢病政策仅降低了因单纯高血压为主的住院服务利用及费用。通过建立双重差分模型分析患者年住院次数、年住院费用及再次住院的影响，结果一致。说明，门诊特殊慢病政策能够影响疾病严重程度较轻患者的住院服务利用，有助于延缓高血压并发症患者的疾病进程。.以高血压患者服务依从性为切入点开展机制研究。采用多阶段抽样方法随机选取了1969名社区管理的高血压患者调查其药物依从性及影响因素，通过logistics回归分析表明门诊医疗保险政策有无与高血压患者的药物不依从性显著相关。进一步将调查对象分为享受门诊特殊慢病政策的患者与未享受的患者，分析两组患者服药依从性的差异，两组服药不依从率分别为10.58%和16.56%。采用非线性的Blinder-Oaxaca分解分析发现近乎一半（44.21%）的药物不依从率的差异能够由观察变量进行解释。需要因素解释了36.66%的药物不依从率的差异。.通过本研究证实门诊慢性病政策提高了慢性病患者的服药依从率和病情较轻患者的住院服务利用，进而影响其疾病发展。医疗保险制度设计覆盖慢性病发展早期的患者才能有助于慢性病的防控。