农村医疗支出型贫困人群医疗保障：需求、就医行为及政策建议

The poverty caused by overload medical out-of-pocket expenditure(objective people) is a kind of people of such poverty status as the medical out-of-pocket expenditure exceed the income. In China, because the reimbursement is still low level of the New Rural Cooperative Medical System and the medical assistant has not covered these objective people, they will not to visit a doctor or be poverty when fall serious sick. Our item will focus on these people, and take their medical demands as the analysis base. With the household investigation, we will get the data of the objective people's socialeconomic conditon, the health condition, medical demands and expenditure burden, and then analyze the influence factors of their medical untilization behavior. With these results, based on the preformed system dynamics(SD) model of health delivery system, we will adjust the parameters such as the socialeconomic condition, medical utilization factor et al.. With the new adjusted model, we can find the common and special rules of medical utilization of the objective people, and the medical burden characters. At last, we will analyze the progress of the policy speical for the objective people in the other Chinese social insurances and medcial insurance system in foreign countries, and design the intervening policies to help these people to access the needed medical care. With the model, we will test the effects of these intervening policies as measure the medical utilization behavior, the medical burden, and financial burden. With the interving test results, we will analyze the feasibility of the policy, and propose the countermeasures.

医疗支出型贫困是一种由于医疗支出超过收入而引发的贫困状态，由于新农合的低水平和医疗救助未将其纳入保障，使之表现为"因病致贫、返贫"或者不去就诊。本研究聚焦现有保障体系及高通胀背景下医疗支出型贫困人群面临的刚性医疗需求可能缺失的现实问题，以医疗支出型贫困人群医疗需求为逻辑起点，通过入户调查，获得其健康状况、社会经济状况、医疗需求及费用负担情况，分析其就医影响因素；以课题组前期构建的农村医疗卫生系统系统动力学模型为依托，以医疗支出型贫困人群就医行为及疾病费用负担变化为观测点，利用就医影响因素等参数调整修正模型，模拟目标人群就医行为的一般及特殊规律，发现其经济负担特征；结合针对医疗支出型贫困人群的其他社会保障制度（我国）及中外医疗保障制度建设改革进程分析，设计干预措施进行干预试验，测算不同支付制度设计下人群的就医行为、医疗负担及财政负担状况，结合方案可行性分析，提出满足其刚性医疗需求的政策建议。

医疗支出型贫困是医疗支出超过收入而引发的贫困，按收入不属于贫困，结余不高，支出风险导致不就诊或因病致贫。外部资金具有高成本收益。全球此类人群占支出型贫困超过1/4。研究聚焦我国缺乏人群针对性保障设计，其面临服务缺失问题，借鉴实践界定标准，发现其就医规律及影响因素；构建就医系统动力学（SD）模型，模拟行为规律；利用影响因素进行干预试验，获得政策干预靶点。.资料方法 包括文献收集及现场调查资料。对四川省米易县、河北省邢台县、江苏省滨海县按收入分层抽样，随机选择3-6个乡镇，选择4～6个行政村进行入户调查。采用规范和实证研究方法。 .结果与结论.一般情况：有效问卷453份，有效率为96.7%。目标人群为主要劳动力，文化水平和就业率低；获得社会救助机会小，人际范围窄，疾病经济风险大。.门诊选择：①治疗方式、首诊机构差异有统计学意义（P＜0.05）。②自我治疗、先自我治疗再就医、直接就医、不治疗为3.3%、50.8%、30.0%、15.9%；③首诊私人诊所、村卫生室、乡镇卫生院、县及以上为10.7%、24.4%、37.2%、27.7%。④就医趋高，因素为基本情况、家庭经济水平、医疗负担及机构可及性（P＜0.05）。.住院选择：①85.2%因病住院，县和地市医院比例分别为54.7%和39.3%，②手术比例高,院前\术前等待天数(3天\2天）不长，满意度高。③次均住院费用高，城乡机构差距明显。④医疗技术、病情、报销是主观影响因素。⑤基本情况、病情、费用及支付等是影响因素（P＜0.01）。⑥可及性将释放潜在趋高需求，需综合机构建设、有序就医及分级支付等制度。.模拟与干预：①构建就医行为流图，由门诊和住院就医决策2模块构成，112个变量。②就医趋高性，门诊以乡镇卫生院为主；70%以上县医院住院。③支付能力提升、服务能力改善及可及性提高，对行为有引导作用，以县域内为主，增长理性。组合政策效果更平衡；乡镇卫生院与县医院对不同政策有敏感性。.政策建议：以县域机构能力和经济性因素为核心，以实现有效就医为靶点，采取综合措施：道德风险小，可作为政策优先对象，纳入社会保障体系；需求可控，建设重点在县域；经济可及性是关键,支付设计和机构建设是改革重点；需关注人群潜在县外就医倾向。.研究首次探讨医疗支出型贫困人群就医行为规律，实现现况与行为仿真相互验证，为政策制定提供数据与模拟平台。