湖南省新型农村合作医疗制度运行现状与发展趋势研究
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摘要
目的通过对湖南省新型农村合作医疗制度(以下简称“新农合”)运行现状进行分析,对2003年—2009年湖南省新农合发展趋势进行纵向研究。客观评估新农合从试点应用到全面实施以来的实施过程和基金运行效益,并对新农合未来三年的发展趋势进行分析和预测。探讨解决新农合工作中存在问题的方法,为合理建立补偿方案与监管制度,为合理配置湖南省卫生资源,促进新型农村合作医疗健康发展提供依据。
方法本次调查对象为湖南省所辖13个市、1个自治州、122个县(市、区)的各级新农合经办机构、定点医疗机构和新农合参合农民。具体方法为：1)对湖南省新农合的现状分析采用一般统计分析方法,以市州为单位对14个市州的新农合资料进行统计分析。统计分析软件为SPSS13.0、Excel2007等；2)对新农合发展趋势研究采用纵向对比、单因素分析等方法,对湖南省新农合从2003年到2010年近8年的原始数据进行建模,用残差灰色预测模型对新农合未来三年的发展趋势进行预测,预测指标为：统筹基金补助受益面、住院补助受益面、住院补助受益度、参合率、次均住院费用、次均补助费用、农民自费金额。3)采用国际疾病分类编码(ICD-10)对新农合住院老年人疾病谱分布进行研究,对2006年到2010年新农合老年人住院前50位病种进行统计分析。
结果
一)湖南省新农合的现状分析：
2009年湖南省有5047.93万农业人口,新型农村合作医疗制度已全省覆盖。
1、参合情况：2009年,湖南省平均参合率达到91.49%,其中参合率最高为长沙市达95.02%,最低为娄底市86.33%,邵阳市、永州市、常德市、湘西州、张家界市、怀化市、娄底市共一半市州参合率均在全省平均水平以下。
2、基金筹集情况：2009年,湖南省的筹资标准为100元/人。其中农民个人缴费20元,中央财政各补助40元,省财政补助24元,市、县两级财政各补助8元,财政补助金额已占到新农合基金总额的80%。
湖南省新农合基金的筹集主要有三个来源：一是各级政府的财政补助资金,二是农民个人缴费资金,三是社会捐助。2009年,湖南省新农合计划筹资464440.55万元,实际筹资478482.82万元,其中中央财政补助资金184727.51万元,地方财产补助资金186666.61万元(其中：省级财政117757.34万元、市级33666.16万元、县级35243.11万元),参合农民自缴资金92364.14万元。财政补助基本上能够按时足额到位,保障新农合制度顺利实施。
3、基金支出情况：2009年,湖南省新农合基金支出总额为474099.6万元,其中统筹基金支出458322.15万元,占基金支出总额的96.67%。基金实际支出占年度筹资总额的99.08%,其中湘潭市为104.11%、邵阳市为100.20%、常德市为105.81%、永州市为100.22%和娄底市为103.56%,均超过100%(启用了往年的沉淀结余资金)。湖南省2009年新农合基金支出以住院补助为主要形式,其中住院补助基金支出占87.20%,门诊补助基金支出占3.92%,定额住院分娩补助基金支出占2.88%,大病特殊门诊补助基金支出占2.61%,体检补助基金支出占0.26%。
4、住院补偿情况
1)住院率：2009年湖南省参合农民住院人次数达到381.28万人次,住院率达8.26%。其中省级医院住院率为0.56%,市级医院住院率为0.70%,县级医院住院率为2.66%,乡级医院住院率为4.34%。从住院率分布来看,农民看病住院主要集中在县、乡两级医院。
2)住院费用：2009年,湖南省住院费用共计960071.55万元,全省次均住院费用为2518.00元。其中娄底市、长沙市、湘潭市、邵阳市、衡阳市5个地市次均住院费用在省平均水平以上,最高的是长沙为3183.40元；次均住院费用低于省平均水平的依次有永州市、株洲市、郴州市、岳阳市、益阳市、常德市、张家界、怀化市和湘西州,最低的是湘西州为1780.03元。
不同级别医疗机构住院费用水平不同,2009湖南省省、市、县、乡各级医疗机构次均住院费用依次为9946.31元、5583.41元、2689.71元和958.51元。其中常德市、邵阳市、益阳市、郴州市的省级、市级、乡级次均费用均高于省平均水平。
3)住院可报费用：2009年,湖南省新农合住院费用中可报费用(指进入统筹计算的费用,等于住院费用一完全政策自付一部分政策自付一起付线)共计807555.93万元,占住院总费用的84.11%,次均可报费用为2117.99元。可报比例最高的是常德市为87.41%,最低的是长沙市为79.62%。可报比例高于省平均水平的除常德市外依次还有怀化市、益阳市、郴州市、湘西州、娄底市、邵阳市、岳阳市、衡阳市；低于省平均水平的有永州市、湘潭市、株洲市、张家界市。
2009湖南省省、市、县、乡各级医疗机构住院次均可报费用依次为7327.65元、4478.41元、2378.86元和904.09元。其中衡阳市、岳阳市、永州市的省、市、县、乡四级次均费用均低于省平均水平。
4)住院补助费用：2009年湖南省的补助金额(等于可报费用×补助比例,即农民获得的实际补偿金额)为399679.85万元,省、市、县、乡各级医疗机构住院补助金额占总住院补助金额比例依次为17.22%、14.54%、38.96%、29.18%。
2009湖南省平均次均住院补助费用为1048.25元,省、市、县、乡各级医疗机构住院次均补助金额依次为2682.65元、1788.58元、1268.96元和582.38元。
5)门诊补偿：2009年,湖南启动门诊统筹试点,参合农民每人每年普通门诊基金补偿标准为10-15元不等,特殊慢性病门诊统筹基金补偿标准为人均5-10元不等。启动门诊统筹试点的县(市、区)共计58个。门诊统筹总补助人次8891560次,补助金额17943.96万元。
5、基金受益度：2009年湖南省住院补助受益度(实际住院补助费用占住院总费用比例)为41.63%,各市州住院补助受益度不均衡,14个地市中有7个地市在省平均水平以上,长沙市、邵阳市、岳阳市等地市的住院补助受益度相对较低。虽然各地区的筹资水平相近,可是补偿受益度却相差很大,其中补助受益度最高的为常德市达46.22%,最低的是长沙市仅为36.46%,补偿受益度最低的地区和补偿受益度最高的地区相差近10个百分点。2009年湖南省省、市、县、乡四级医疗机构次均住院补助受益度分别为26.97%,32.03%,47.18%,60.76%。长沙市、张家界市和益阳市的省、市、县、乡四级次均住院补助受益度均低于省平均水平；岳阳市、常德市、永州市和湘西州的省、市、县、乡四级次均住院补助受益度均高于省平均水平。
6、基金受益面：2009年,全省统筹基金住院补偿受益面(住院补助人次占总住院人次比例)为32.85%,各市州住院补助受益面不均衡,最高为益阳市83.60%,最低为娄底市12.12%,仅有益阳市、岳阳市、常德市、张家界、湘潭市、怀化市6个市受益面在省平均水平以上。
二)湖南省新农合2003—2009年发展趋势分析：
1、参合情况：湖南省新农合的首批试点工作从2003年7月份正式开始,因此通常我们将2003年7月到2004年12月归为第一个运行年度。第一个运行年度新农合制度仅覆盖农业人口342万人,随着新农合制度的不断完善,新农合覆盖范围也在逐年扩大。2005年新增醴陵等9个试点县(市、区),覆盖农业人口912万人。2006年试点县(市、区)数达到43个,覆盖农业人口2463.5万人。2007年新农合县市区达到99个,覆盖农业人口4796.9万人。2008年全省新农合实施县市区达到122个,实现了新农合制度的全面覆盖,到2009年全省参合率为91.22%。2003年到2009年间,湖南新农合参合率一直呈上升趋势,但仍略低于中部地区平均水平(92.15%),且与全国平均水平仍有一定差距,相差2.97%。
2、基金筹集情况：自2003年启动试点到2009年全面实施,湖南新农合筹资水平在逐步提升：2003年新农合筹资标准为30元/人,其中财政补助20元,农民个人负担10元；2006年农民个人缴纳不变,总筹资标准提高为50元/人；2008年总筹资标准又提高到80元/人,农民个人缴纳金额仍为10元；2009年筹资标准继续提高到100元/人,其中财政补助标准为80元/人,个人缴费标准也提高为20元/人；到2010年全省新农合筹资标准提高到每人每年140元,其中各级财政补助标准提高到每人每年120元。省本级和各市州、县(市、区)每年均确保了财政补助资金及时足额到位,财政补助资金已占到新农合基金总额的80%以上,其中中央财政补助约占40%为主要基金来源。
3、基金支出情况：2003-2009年全省统筹基金使用率呈上升趋势,依次为70.00%、80.94%、80.60%、88.82%、90.20%、103.62%(部分地区启用了往年结余资金),省统筹基金平均使用率为94.43%。截至2009年12月,湖南省新农合总补助人次数为3321.9328万人次,统筹基金支出为1025261.4万元。
统筹基金支出主要用于住院补助、定额住院分娩补助、大病特殊门诊补助、体检补助等,其中累计住院补助占累计统筹基金支出89.95%,累计定额住院分娩补助占累计统筹基金支出2.45%,累计大病特殊门诊补助占累计统筹基金支出2.71%,累计体检补助占累计统筹基金支出0.76%。
4、住院补偿情况
1)次均住院费用：2003年到2009年间,湖南省的总体住院费用水平呈缓慢上升趋势,2008年达到2621.52元/人次,较2003年增长9.71%,在2009年增长态势得到控制,费用较2008年下降103.52元,下降O.04%。
2)次均住院补助费用：2003年到2009年间,湖南的次均住院补助费用在逐年提高,住院补助水平呈上升趋势,特别是随着2008和2009年筹资标准的提高,费用补助增长的幅度也较大。2003年次均住院费用补助金额仅为639.18元,补助比例为26.75%,2009年次均住院补助费用增加到1048.24元,补助比例也提升到41.63%。
3)次均自费费用：2003年到2009年间,虽然农民住院费用在逐年增加,但新农合次均补助费用的增长幅度却一直大于住院费用的增长,所以农民自付部分的费用一直在减少,由2003年的1750.28元减少到1469.75元,自费比例由73.25%下降到58.37%。
4)住院医院级别分布：全省住院人次分布在乡镇卫生院最多,县级医疗机构次之,县级以上医疗机构就诊人次较少,最少的是省级医疗机构。从2008年开始在省级医疗机构就诊的农合病人有增多趋势,就诊率从5.69%增加到6.77%。2009年除市级医疗机构就诊率减少外,其他三级医疗机构就诊率均有所提高,病员开始有从市级医疗机构向两端分流的趋势,即向上流向省级医疗机构,向下流向县、乡两级医疗机构。
5)资金流向：县级补助费用最多,市级补助费用最少。新农合统筹基金主要用于农民在县、乡两级医疗机构住院的补助费用,其补偿金额占统筹基金的70%左右。从资金流向来看,湖南新农合政策变动平缓,省、市、县三级的补助比例在逐年增加,而乡级补助比例在逐年下调。
5、住院率：2009年参合农民住院人次数达3812840次,7年间住院率从4.57%增长到8.26%,增长幅度较大。
6、住院补偿政策：对调查样本中补偿政策信息完整的71个县(市、区)农合补偿政策进行分析,并对这71个样本县2007年到2009年间的原始数据进行统计：起付线的高低与次均住院费用(r=0.8067,p=1)和次均补偿费用(r=0.6211,p=1)的高低有正相关关系,封顶线的高低与次均住院费用(r=0.0483,p=1)无相关关系、与次均住院补偿费用(r=0.1986,p=1)有正相关关系。
7、统筹基金受益面：虽然统筹基金补助受益面在2007年间有所下降,但基金效益整体呈上升趋势,受益面在逐年提升。最初2003年度的统筹基金补助受益面和住院补助受益面分别4.57%和2.80%,到2009年已经增加至32.65%和8.26%。
8、统筹基金受益度：2003年到2009年,湖南新农合住院补助受益度呈上升趋势,特别是在2008、2009两年间,增长幅度较往年明显增大。2003年的统筹基金补助受益度为26.75%,到2009年已经增加至41.63%,较2003年增长14.88个百分点。
9、趋势预测：通过残差灰色预测模型预测结果来看,参合率、次均住院补助费用、统筹基金补助受益面、住院补助受益面、住院补助受益度均呈上升趋势,而农民自费金额也将逐步下降,说明湖南省新农合将能够持续发展,新农合整体运行效益呈上升趋势。次均住院费用有增长趋势,未来三年将按2.757%、2.759%、2.761%的速率增长。
三)老年农民住院疾病谱研究
1、参合率：2006年-2010年湖南省65岁及以上老年人参加新农合的人数由664934人增加到2611754人,参合率由75.39%增加到95.37%。
2、住院率：2006年-2010年湖南省65岁及以上老年人住院人次由63254增加到514170人次,住院率由9.51%增加到19.69%。
3、疾病构成：湖南省老年人所患疾病以呼吸系统疾病最多,以2010年数据为例前十位疾病中,呼吸系统疾病占50.34%。按疾病分类分,2010年排在前十位的疾病依次是肺部感染、冠心病、慢性支气管炎、高血压、心绞痛、慢性支气管炎急性发作、脑梗塞、肺源性心脏病、脑梗死、肺炎。5年来前10位住院疾病略有变化,排在第一位的一直是肺部感染,冠心病心绞痛、高血压、肺炎、慢性支气管炎、脑梗死、冠心病六种疾病也一直位居前十位。
结论
1、湖南省新型农村合作医疗制度平稳运行。新农合制度实施以来,农民参合率稳步提高,财政补助大幅增加,资金足额筹集到位,新农合整体运行效益呈上升趋势,参合农民受益程度逐年提高。
2、新农合制度的实施促进了农村卫生事业发展。通过新农合制度费用补偿机制的动态调节,合理引导农民就医,有利于促进医疗卫生资源的优化分配,增强卫生服务的可及性,从一定程度上改变了农村卫生的现状。
3、影响基金运行效益的主要因素。补偿比例、起付线的高低是影响住院补助受益面的主要因素。补助受益度不一定与经济情况成正比,而与基金支出计划、补偿比例相关。补偿比例对新农合的受益水平和参合农民的择医就诊取向有较大影响。起付线对住院补助受益面的影响一般呈负相关,起付线越高则受益面越窄,起付线越低则受益面越宽。门诊统筹基金可有效扩大新农合的受益面。
4、新农合存在的主要问题。1)住院率有增长过快的趋势。新农合制度的实施在一定程度上激发了农民的医疗需求,但住院率有增长过快的趋势,已经超出了由于新农合制度本身激发出的医疗需求所带来的增长范畴。2)新农合病员、资金流向有变化。新农合病员、资金流向有由乡级医疗机构向县级医疗、省级医疗机构流动的趋势。
5、湖南省参合老年农民主要疾病。本次研究显示肺部感染、冠心病、慢性支气管炎、高血压、心绞痛、慢性支气管炎急性发作、脑梗塞、肺源性心脏病、脑梗死、肺炎等病是老年人易患的常见病种,对老年人健康危害较大。
6、新型农村合作医疗制度仍是一低水平保障制度。新型农村合作医疗制度是一农民自愿参加的互助共济的制度,还不是真正意义上的社会保障制度,它的特点是低水平、广覆盖,保障水平和保障程度是有限的,是农村医疗保障制度的初级阶段,是一种低水平的农村基本医疗保障制度。
Objective Analysis of Hunan Province, the new rural cooperative medical system (hereinafter referred to as the "new rural cooperative") to run the status quo, Hunan Province in2003-2009the new rural cooperative development trend of the longitudinal study, a comprehensive survey to acquire the relevant information, the Participatingthe fund raising, fund expenditures, the compensation of the five aspects and the operational benefits of the Fund in-depth analysis. An objective assessment of the new rural cooperative from the pilot application to the implementation process since the full implementation of the operational benefits of the Fund, the farmers really get the benefit, analyze and forecast the future trend of development of the new rural cooperative to explore problems in the new rural cooperative work method for the reasonable compensation scheme established by the regulatory regime for the rational allocation of health resources in Hunan Province, to promote the development of new rural cooperative medical health and to provide a basis.Hunan Province2006-2010participating elderly hospitalization data from the disease constitute the distribution of statistical analysis to understand the onset of disease prevalence and distribution characteristics, a clear onset of disease prevention and control work priorities, to provide for future population health interventionbasis.
Method The survey was conducted under the jurisdiction of13cities in Hunan Province, an autonomous prefectures and122counties (cities, districts) of all levels of the new rural cooperative agencies, designated medical institutions and the new rural cooperative Participating Farmers. The survey sampling, Hunan Province,2009the province of all counties (districts) and the new rural cooperative data, data analysis methods, using statistical analysis software-related data collection, collation and analysis. As follows:1) general statistical analysis of the status quo analysis of Hunan Province, the new rural cooperative of14cities and prefectures (Changsha City, Zhuzhou, Xiangtan, Hengyang, Shaoyang City, Yueyang, Changde City, Zhangjiajie, Yiyang City, Chenzhou City, Yongzhou, Huaihua City, Loudi City, Xiangxi state), the new rural cooperative medical information to cities and prefectures as a unit for statistical analysis. Statistical analysis software SPSS13.0, Excel, etc.;2) the years of2003-2009, the new rural cooperative development trends in the use of vertical contrast, the univariate analysis, trend prediction using residual gray forecasting model to predict;3) hospitalized elderly spectrum of disease distribution using the international classification of Diseases codes (ICD-10),2006to2010, before the new rural cooperative elderly hospitalized50patients for statistical analysis.
Result50,479,300of the agricultural population, the new rural cooperative medical care system has been fully covered in Hunan Province in2009.
I The Hunan NRCMS Analysis:
a. Participating:In2009, Hunan Province, the average participation rate to reach91.49%, which parameters together rate the highest for the Changsha City up to95.03%, minimum Loudi City,86.33%, Shaoyang City, Yongzhou, Changde City, Xiangxi state, Zhangjiajie CityHuaihua City, Loudi City half of the City, state Senate combined rate below the provincial average.
b. Fund-raising:In2009, the funding criteria of Hunan Province is100yuan/person. Individual farmers pay20yuan, the central financial subsidy of40yuan, the provincial government subsidy of24yuan, cities, counties two fiscal subsidies, government subsidies accounted for80%of the total amount of the new rural cooperative fund.
Hunan Province, the new rural cooperative fund raising from three sources:First, governments at all levels of financial subsidies for individual farmers to pay funds, social contributions. In2009, Hunan Province, the new rural cooperative plan to raise4,644,405,500yuan, the actual funding of4,784,828,200yuan, of which1.84billion yuan from the central budget funds, local property grant funds of1.86billion yuan (provincial finance1,177,573,400yuan, Municipal Finance336661600yuan, county finance352,431,100yuan), the urban and rural self-pay924million yuan of funds. Financial assistance is basically on time in full and in place to protect the new rural cooperative medical system to the smooth implementation.
c. Fund expenditure:2009, Hunan Province medical fund expenditures amounted to4740996000yuan, the co-ordinated fund expenditure4583221500yuan, accounting for96.67%of the total fund expenditure. The actual expenditures accounted for annual fund raising a total ratio of99.08%, of which Xiangtan city104.11%, Shaoyang100.20%, Changde105.81%, Yongzhou100.22%and Loudi103.56%, more than100%. In2009Hunan Province medical fund expenditure to hospitalization subsidy as the main form, including hospitalization subsidy fund expenditures accounted for87.20%, ambulatory grant expenditures accounted for3.92%, fixed hospital maternity benefits fund expenditures accounted for2.88%, serious special outpatient grant expenditures accounted for2.61%, subsidy fund expenditures accounted for0.26%.
4. Hospital compensation
1) hospitalization rates:in2009Hunan Province farmers in times reached38128400people, hospitalization rate8.26%. The provincial hospital hospitalization rate was0.56%, the rate of hospitalization for0.70%municipal hospital, county hospital hospitalization rate was2.66%, the rate of hospitalization for4.34%Township hospitals. From the inpatient rate distribution, the farmer sees a doctor the inpatient mainly concentrated in the county and township level two hospital.
2) hospital costs:2009, Hunan hospital for a total cost of9600715500yuan, the average hospitalization expenses for2518yuan. Which Loudi City, Changsha City, Xiangtan City, Shaoyang City, Hengyang city of5ground city, the average hospitalization expenses in provincial above average level, is the highest in Changsha for3183.40yuan; the average hospitalization expenses were lower than average level of the province are Yongzhou City, Zhuzhou City, Chenzhou City, Yueyang City, Yiyang City, Changde City, Zhangjiajie, Huaihua and Xiangxi, Xiangxi is the lowest is1780.03yuan.
Medical institutions of different levels in different levels of hospital costs,2009Hunan Province, city, county, township medical institutions at all levels of the average hospitalization expenses were9946.31yuan, 5583.41yuan,2689.71yuan and958.51yuan. Changde City, Shaoyang City, Yiyang City, Chenzhou City, provincial, municipal, township average costs are higher than the provincial average.
3) can be reported to cost:2009, Hunan province hospitalization expenses for a total cost of8075559300yuan, accounting for the total hospitalization expenses of84.11%times can be reported, the cost is2117.99yuan. May report the highest proportion of Changde city is87.41%, is the lowest in Changsha City for79.62%. Can report proportion is higher than the provincial average with the exception of Changde in Huaihua City, Yiyang City, and Chenzhou City, Xiangxi, Loudi City, Shaoyang City, Yueyang City, Hengyang city; below the provincial average also has the city of Yongzhou, Xiangtan City, Zhuzhou City, Zhangjiajie city.
2009Hunan Province, city, county, township medical institutions at all levels of hospital times can be reported fees were7327.65yuan,4478.41yuan,2378.86yuan and904.09yuan. Hengyang City, Yueyang City, Yongzhou Province, city, county, countryside four class are costs are lower than the average level of the province.
d. the hospital compensation:in2009Hunan province subsidy amount is3996798500yuan, province, city, county, township medical institutions at all levels of hospitalization reimbursement amount total hospitalization subsidy ratio was17.22%,14.54%,38.96%,29.18%.
2009Hunan province average average hospitalization subsidy costs1048.25yuan, province, city, county, township medical institutions at all levels of hospital are the amount of compensation in the order of2682.65yuan,1788.58yuan,1268.96yuan and582.38yuan, the proportion of subsidy is respectively26.97%,32.03%,47.18%,60.76%. Changsha City, Zhangjiajie city and Yiyang city of province, city, county, countryside four class are hospitalization subsidy ratio were lower than the provincial average; Yueyang City, Changde City, Yongzhou city and Xiangxi Province, city, county, countryside four class are hospitalization subsidy ratio were higher than the provincial average.
e. outpatient compensation:2009, Hunan started out-patient co-ordinate the pilot, farmers per person per year of average outpatient service fund compensation standards for the10-15yuan, special chronic out-patient co-ordinate the fund compensation standards for the5-10of average per capita per month. Start the out-patient co-ordinate the pilot county (city, area) for a total of58, of which11counties of Yongzhou city all start, Changsha City, Xiangtan city and Chenzhou city did not begin out-patient co-ordinate the pilot job. Out-patient co-ordinate trips8891560times total subsidy, subsidy179439600yuan.
f. Benefit of fund:In2009Hunan province average hospitalization benefit degree is41.63%, each city state hospitalization subsidy benefit is not balanced,14cities in7cities in the province the proportion of subsidy is above average, Changsha City, Shaoyang City, Yueyang city and other places City hospitalization subsidy level is relatively low. Although the regional funding levels are similar, but the compensation levels differ greatly, which grants the highest proportion of Changde city of46.22%, was the lowest in Changsha City is only36.46%, the lowest percentage in compensation and compensation with the highest proportion of area difference of nearly10percentage points.
g. Benefit from the surface of fund:In2009, the fund as a whole the average hospitalization benefits coverage is32.85%, each city state hospitalization subsidy benefit is not balanced, the highest for the city of Yiyang in83.60%, the lowest in Loudi city for12.12%, only Yiyang City, Yueyang City, Changde City, Zhangjiajie, Xiangtan, Huaihua6city in the province of above average yield surface.
Ⅱ.2003-2009in Hunan province new rural cooperative medical system development trend analysis
a. Participation:Hunan province the first batch of pilot work of new rural cooperative medical system from2003July officially began, so usually we will in2003July to2004December to the first operating year. The first operation year in new rural cooperative medical system covering only the agricultural population of3420000people, along with the new rural cooperative medical system is ceaseless and perfect, the coverage is expanding year by year. In2005the new Liling9pilot counties (city, area), covering the agricultural population of9120000people.2006pilot counties to count to43, covering the agricultural population of24635000people. In2007the new County Urban reached99, covering the agricultural population of47969000people. The implementation of complete2008province county urban reached122, implementation of the new rural cooperative medical system comprehensive coverage, to complete2009province participation rate is91.22%. From2003to2009, the Hunan medical participation rate has been on the rise, but still slightly lower than the average level of central area, and the national average level still has certain difference, a difference of2.97%.
b. Fund raising situation
Starting from2003-2009pilot to carry out in the round, Hunan NCMS financing level gradually upgrade:in2003the NCMS financing standard is30yuan/person, including the fiscal subsidy of20yuan, farmer burden10yuan;2006farmer individual pay is changeless, raise standards for50yuan/person; in2008the total funding standard was raised to80yuan/person, individual farmers to pay the amount still is10yuan of;2009funding standard continued to improve until100yuan/person, including financial subsidy standard is80yuan/person, individual payment standard also increased to20yuan/person; to complete2010province the NCMS financing standard is raised to140yuan per person per year, of which all levels of financial subsidies standards to120yuan per person per year. Provincial and municipal, county urban district each year to ensure that the financial subsidies in place in full and on time, financial subsidy funds have accounted for more than80%of the total amount of NCMS fund of central finance allowance, which accounts for about40%of main fund source.
c. fund expenditure
2003-2009years complete province overall fund utilization rate shows ascendant trend, followed by70%,80.94%,80.60%,88.82%,90.20%,103.62%, the province plans as a whole the average fund usage rate of94.43%. As of2009December, Hunan Province, the total subsidy number33219328person-time, pooling fund expenses for102252614000yuan. Fund expenditure is mainly used for hospitalization subsidy subsidize hospitalized childbirth, illness, quota special outpatient subsidies, subsidy, which cumulative hospitalization subsidy accounting for cumulative overall fund89.95%, fixed hospital maternity benefits accumulated fund expenditure accounted for2.45%, serious special outpatient subsidies or accumulated fund expenditure of2.71%, accumulative total subsidy fund expenditure accounted for0.76%.
Ⅲ Hospital compensation
a. the average hospitalization expenses:From2003to2009, the Hunan province overall hospitalization expenses level was slow ascendant trend, in2008reached2621.52yuan/passengers, a9.71%increase over2003-2009growth under control, cost relatively dropped somewhat2008less103.52yuan, down0.04%.
b. Average hospitalization subsidies:From2003to2009, Hunan's average hospitalization subsidy costs increase year by year, hospitalization subsidy level is rising, especially with the2008and2009to raise standards, the growth rate is also higher cost subsidy. In2003the hospital costs are subsidy amount is only639.18yuan, accounting for26.75%of the total cost, average hospitalization expenses in2009increased to1048.24yuan, the proportion of subsidy was elevated to41.63%.
c. Self cost:From2003to2009, although the farmer hospitalization expenses increased year by year, but the average cost of subsidies has been greater than the growth rate of inpatient cost growth, so the farmer pays part of the cost has been reduced, by2003,1750.28yuan to1469.75yuan reduction, at their own expense subsidy ratio decreased from73.25%to58.37%.
d. inpatient hospital level distribution:The province's hospitalization subsidy trips distribution in township health centers in most medical institutions at county level, the structure of medical assistance at the county level or above, is the least number of less, provincial medical organizations. From the beginning of2008in the provincial medical institution of agricultural patients is increasing, visiting rate increased from5.69%to6.77%. In2009the municipal medical treatment rate is reduced, the other three level medical treatment rates have improved, the patient began to have from the municipal medical institutions to the ends of diversion trends, namely to the provincial medical organizations, downward County, countryside two class medical institutions.
f. capital flows:Grant passengers flow and grant funding disproportionately, county subsidy proportion is the largest, the smallest proportion of municipal subsidies. New rural cooperative medical fund is mainly used for farmers in County, countryside two class medical institutions hospitalization subsidy costs, the amount of compensation for the overall amount of about70%. Capital flows from the point of view, the Hunan new policy changes gently, province, city and county level three the proportion of subsidy increases year by year, and the proportion of subsidy in cut each year.
g. hospitalization rate:2009peasants inpatients number to be amounted to3812840times, in7years the rate increased from4.57%to8.26%, growth range is bigger
h. the hospital compensation policy:On14city state of compensation policy information complete71counties (city, area) agricultural compensation policy were analyzed, and the71sample counties from2007to2009of the original statistical data:deductible level and average hospitalization expenses (r=0.8067, p=1) and time (compensation costs r=0.6211, p=1) or there is a positive correlation between the top line, the level of the average hospitalization expenses (r=0.0483,p=1) there is no correlation, and compensation are cost (r=0.1986, p=1) there is a positive correlation between. i. pooling fund benefit:Although the whole fund subsidy benefit in
2007years has declined, but the fund benefits the overall upward trend, benefit to promote in year after year. The initial2003year whole fund subsidy benefit and hospitalization subsidy benefit surface are respectively4.57and2.80%, and2009has been increased to32.65and8.26%.
j. pooling fund earning degrees:2003to2009, Hunan hospitalization subsidy benefit degree shows ascendant trend, especially in2008,2009in two years, the growth rate of a noticeably increases.2003fund subsidy benefit of26.75%, to2009already increased to41.63%, compared to2003increased55.63percentage points.
IV Investigation on disease spectrum of elderly hospitalized farmers
a. the participation rate:2006-2010in Hunan province in the elderly aged65and above in the new rural cooperative medical system number increased from664934to2611754, from75.39%to95.37%participating.
b. hospitalization rate:2006-2010in Hunan province in the elderly aged65and above by63254person-time inpatients to increase514170person-time, hospitalization rate from9.51%to19.69%.
c. disease:Disease system respectively to the respiratory system up to2010, data of the top ten diseases, respiratory system50.34%. According to the classification of diseases,2010in the top ten diseases were pulmonary infection, chronic bronchitis, coronary heart disease, hypertension, coronary heart disease angina, acute exacerbations of chronic bronchitis, cerebral infarction, pulmonary heart disease, cerebral infarction, pneumonia.5years before the10inpatients with slight variations, in the first row is always a lung infection, the rest has been among the top ten of angina pectoris of coronary heart disease, hypertension, chronic bronchitis, pneumonia, cerebral infarction.
Conclusion
Ⅰ. The Hunan province new rural cooperative medical system running smoothly.
The new rural cooperative medical system comprehensive coverage since, farmer participation rate rises steadily, financial subsidy increases considerably, funds raised in new rural cooperative medical system in full, the overall operation efficiency rise, the participants'benefit degree increase year by year, effectively alleviates the peasants'economic burden of disease.
Ⅱ. The new rural cooperative medical system has promoted the implementation of the development of rural health service.
The new rural cooperative medical system the cost of compensating regulation, reasonable guiding farmers cooperative medical system and medical treatment, the development of rural health service has formed a complementary, mutually reinforcing relationship. Patient flow changes conducive to promoting health and reasonable utilization of resources, enhance health services accessibility, from a certain extent changed the status quo of rural health.
Ⅲ. The main factors influencing fund operating efficiency.
Compensation ratio, deductible level is the main factor influencing hospitalization subsidy benefit. Subsidy level is not certain and economic situation is proportional, and fund spending plan, compensation ratio. Proportion of compensation for new rural cooperative medical system benefit level and farmers' choice of medical treatment orientation has great influence. Deductible on hospitalization subsidy benefit affecting the general was negatively related to pay lines, high benefit face more narrow, less deductible will benefit the wider. Compensation line cap affects new rural cooperative medical system to alleviate farmers'poverty caused by diseases, to play the role of.5, out-patient co-ordinate the fund can effectively expand the medical benefit, to relieve the pressure of outpatient medical costs, improve and consolidate the majority of farmers ' enthusiasm, has the very vital significance.
Ⅳ. The main problem.
A new type of rural cooperative medical system in the implementation of a certain extent of excitation of the farmer's medical needs, but the rate of hospitalization, hospitalization costs have fast growth trend, already exceeded due to the new rural cooperative medical system itself inspired the medical needs of the growing category, the presence of excessive medical risk.
Ⅳ Hunan Province, farmers'main diseases.
This study showed that pulmonary infection, chronic bronchitis, coronary heart disease, hypertension, coronary heart disease angina, acute exacerbations of chronic bronchitis, cerebral infarction, pulmonary heart disease, cerebral infarction, pneumonia and other diseases that predispose the elderly to common diseases on the health of the elderly, great harm. The new rural cooperative medical system is a farmer to participate in voluntary mutual aid system, not the true sense of the social security system, it is characterized by low level, wide coverage, so the security level and the security level is limited. With the city's basic medical insurance, new rural cooperative medical security strength is lesser, regulations to be sound,
Ⅵ. New rural cooperative medical system is still a low level security system.
management needs to be further standardized, efforts need to be further more. Can say, the new rural cooperative medical system is the rural medical security system in the primary stage, is a low level of rural basic medical security system. In this sense, the new cooperative medical system is in a transition period from junior to senior development, need various government support and attention, governments at all levels will also be in the implementation of the new rural cooperative medical processes play a more important role.
方法本次调查对象为湖南省所辖13个市、1个自治州、122个县(市、区)的各级新农合经办机构、定点医疗机构和新农合参合农民。具体方法为：1)对湖南省新农合的现状分析采用一般统计分析方法,以市州为单位对14个市州的新农合资料进行统计分析。统计分析软件为SPSS13.0、Excel2007等；2)对新农合发展趋势研究采用纵向对比、单因素分析等方法,对湖南省新农合从2003年到2010年近8年的原始数据进行建模,用残差灰色预测模型对新农合未来三年的发展趋势进行预测,预测指标为：统筹基金补助受益面、住院补助受益面、住院补助受益度、参合率、次均住院费用、次均补助费用、农民自费金额。3)采用国际疾病分类编码(ICD-10)对新农合住院老年人疾病谱分布进行研究,对2006年到2010年新农合老年人住院前50位病种进行统计分析。
结果
一)湖南省新农合的现状分析：
2009年湖南省有5047.93万农业人口,新型农村合作医疗制度已全省覆盖。
1、参合情况：2009年,湖南省平均参合率达到91.49%,其中参合率最高为长沙市达95.02%,最低为娄底市86.33%,邵阳市、永州市、常德市、湘西州、张家界市、怀化市、娄底市共一半市州参合率均在全省平均水平以下。
2、基金筹集情况：2009年,湖南省的筹资标准为100元/人。其中农民个人缴费20元,中央财政各补助40元,省财政补助24元,市、县两级财政各补助8元,财政补助金额已占到新农合基金总额的80%。
湖南省新农合基金的筹集主要有三个来源：一是各级政府的财政补助资金,二是农民个人缴费资金,三是社会捐助。2009年,湖南省新农合计划筹资464440.55万元,实际筹资478482.82万元,其中中央财政补助资金184727.51万元,地方财产补助资金186666.61万元(其中：省级财政117757.34万元、市级33666.16万元、县级35243.11万元),参合农民自缴资金92364.14万元。财政补助基本上能够按时足额到位,保障新农合制度顺利实施。
3、基金支出情况：2009年,湖南省新农合基金支出总额为474099.6万元,其中统筹基金支出458322.15万元,占基金支出总额的96.67%。基金实际支出占年度筹资总额的99.08%,其中湘潭市为104.11%、邵阳市为100.20%、常德市为105.81%、永州市为100.22%和娄底市为103.56%,均超过100%(启用了往年的沉淀结余资金)。湖南省2009年新农合基金支出以住院补助为主要形式,其中住院补助基金支出占87.20%,门诊补助基金支出占3.92%,定额住院分娩补助基金支出占2.88%,大病特殊门诊补助基金支出占2.61%,体检补助基金支出占0.26%。
4、住院补偿情况
1)住院率：2009年湖南省参合农民住院人次数达到381.28万人次,住院率达8.26%。其中省级医院住院率为0.56%,市级医院住院率为0.70%,县级医院住院率为2.66%,乡级医院住院率为4.34%。从住院率分布来看,农民看病住院主要集中在县、乡两级医院。
2)住院费用：2009年,湖南省住院费用共计960071.55万元,全省次均住院费用为2518.00元。其中娄底市、长沙市、湘潭市、邵阳市、衡阳市5个地市次均住院费用在省平均水平以上,最高的是长沙为3183.40元；次均住院费用低于省平均水平的依次有永州市、株洲市、郴州市、岳阳市、益阳市、常德市、张家界、怀化市和湘西州,最低的是湘西州为1780.03元。
不同级别医疗机构住院费用水平不同,2009湖南省省、市、县、乡各级医疗机构次均住院费用依次为9946.31元、5583.41元、2689.71元和958.51元。其中常德市、邵阳市、益阳市、郴州市的省级、市级、乡级次均费用均高于省平均水平。
3)住院可报费用：2009年,湖南省新农合住院费用中可报费用(指进入统筹计算的费用,等于住院费用一完全政策自付一部分政策自付一起付线)共计807555.93万元,占住院总费用的84.11%,次均可报费用为2117.99元。可报比例最高的是常德市为87.41%,最低的是长沙市为79.62%。可报比例高于省平均水平的除常德市外依次还有怀化市、益阳市、郴州市、湘西州、娄底市、邵阳市、岳阳市、衡阳市；低于省平均水平的有永州市、湘潭市、株洲市、张家界市。
2009湖南省省、市、县、乡各级医疗机构住院次均可报费用依次为7327.65元、4478.41元、2378.86元和904.09元。其中衡阳市、岳阳市、永州市的省、市、县、乡四级次均费用均低于省平均水平。
4)住院补助费用：2009年湖南省的补助金额(等于可报费用×补助比例,即农民获得的实际补偿金额)为399679.85万元,省、市、县、乡各级医疗机构住院补助金额占总住院补助金额比例依次为17.22%、14.54%、38.96%、29.18%。
2009湖南省平均次均住院补助费用为1048.25元,省、市、县、乡各级医疗机构住院次均补助金额依次为2682.65元、1788.58元、1268.96元和582.38元。
5)门诊补偿：2009年,湖南启动门诊统筹试点,参合农民每人每年普通门诊基金补偿标准为10-15元不等,特殊慢性病门诊统筹基金补偿标准为人均5-10元不等。启动门诊统筹试点的县(市、区)共计58个。门诊统筹总补助人次8891560次,补助金额17943.96万元。
5、基金受益度：2009年湖南省住院补助受益度(实际住院补助费用占住院总费用比例)为41.63%,各市州住院补助受益度不均衡,14个地市中有7个地市在省平均水平以上,长沙市、邵阳市、岳阳市等地市的住院补助受益度相对较低。虽然各地区的筹资水平相近,可是补偿受益度却相差很大,其中补助受益度最高的为常德市达46.22%,最低的是长沙市仅为36.46%,补偿受益度最低的地区和补偿受益度最高的地区相差近10个百分点。2009年湖南省省、市、县、乡四级医疗机构次均住院补助受益度分别为26.97%,32.03%,47.18%,60.76%。长沙市、张家界市和益阳市的省、市、县、乡四级次均住院补助受益度均低于省平均水平；岳阳市、常德市、永州市和湘西州的省、市、县、乡四级次均住院补助受益度均高于省平均水平。
6、基金受益面：2009年,全省统筹基金住院补偿受益面(住院补助人次占总住院人次比例)为32.85%,各市州住院补助受益面不均衡,最高为益阳市83.60%,最低为娄底市12.12%,仅有益阳市、岳阳市、常德市、张家界、湘潭市、怀化市6个市受益面在省平均水平以上。
二)湖南省新农合2003—2009年发展趋势分析：
1、参合情况：湖南省新农合的首批试点工作从2003年7月份正式开始,因此通常我们将2003年7月到2004年12月归为第一个运行年度。第一个运行年度新农合制度仅覆盖农业人口342万人,随着新农合制度的不断完善,新农合覆盖范围也在逐年扩大。2005年新增醴陵等9个试点县(市、区),覆盖农业人口912万人。2006年试点县(市、区)数达到43个,覆盖农业人口2463.5万人。2007年新农合县市区达到99个,覆盖农业人口4796.9万人。2008年全省新农合实施县市区达到122个,实现了新农合制度的全面覆盖,到2009年全省参合率为91.22%。2003年到2009年间,湖南新农合参合率一直呈上升趋势,但仍略低于中部地区平均水平(92.15%),且与全国平均水平仍有一定差距,相差2.97%。
2、基金筹集情况：自2003年启动试点到2009年全面实施,湖南新农合筹资水平在逐步提升：2003年新农合筹资标准为30元/人,其中财政补助20元,农民个人负担10元；2006年农民个人缴纳不变,总筹资标准提高为50元/人；2008年总筹资标准又提高到80元/人,农民个人缴纳金额仍为10元；2009年筹资标准继续提高到100元/人,其中财政补助标准为80元/人,个人缴费标准也提高为20元/人；到2010年全省新农合筹资标准提高到每人每年140元,其中各级财政补助标准提高到每人每年120元。省本级和各市州、县(市、区)每年均确保了财政补助资金及时足额到位,财政补助资金已占到新农合基金总额的80%以上,其中中央财政补助约占40%为主要基金来源。
3、基金支出情况：2003-2009年全省统筹基金使用率呈上升趋势,依次为70.00%、80.94%、80.60%、88.82%、90.20%、103.62%(部分地区启用了往年结余资金),省统筹基金平均使用率为94.43%。截至2009年12月,湖南省新农合总补助人次数为3321.9328万人次,统筹基金支出为1025261.4万元。
统筹基金支出主要用于住院补助、定额住院分娩补助、大病特殊门诊补助、体检补助等,其中累计住院补助占累计统筹基金支出89.95%,累计定额住院分娩补助占累计统筹基金支出2.45%,累计大病特殊门诊补助占累计统筹基金支出2.71%,累计体检补助占累计统筹基金支出0.76%。
4、住院补偿情况
1)次均住院费用：2003年到2009年间,湖南省的总体住院费用水平呈缓慢上升趋势,2008年达到2621.52元/人次,较2003年增长9.71%,在2009年增长态势得到控制,费用较2008年下降103.52元,下降O.04%。
2)次均住院补助费用：2003年到2009年间,湖南的次均住院补助费用在逐年提高,住院补助水平呈上升趋势,特别是随着2008和2009年筹资标准的提高,费用补助增长的幅度也较大。2003年次均住院费用补助金额仅为639.18元,补助比例为26.75%,2009年次均住院补助费用增加到1048.24元,补助比例也提升到41.63%。
3)次均自费费用：2003年到2009年间,虽然农民住院费用在逐年增加,但新农合次均补助费用的增长幅度却一直大于住院费用的增长,所以农民自付部分的费用一直在减少,由2003年的1750.28元减少到1469.75元,自费比例由73.25%下降到58.37%。
4)住院医院级别分布：全省住院人次分布在乡镇卫生院最多,县级医疗机构次之,县级以上医疗机构就诊人次较少,最少的是省级医疗机构。从2008年开始在省级医疗机构就诊的农合病人有增多趋势,就诊率从5.69%增加到6.77%。2009年除市级医疗机构就诊率减少外,其他三级医疗机构就诊率均有所提高,病员开始有从市级医疗机构向两端分流的趋势,即向上流向省级医疗机构,向下流向县、乡两级医疗机构。
5)资金流向：县级补助费用最多,市级补助费用最少。新农合统筹基金主要用于农民在县、乡两级医疗机构住院的补助费用,其补偿金额占统筹基金的70%左右。从资金流向来看,湖南新农合政策变动平缓,省、市、县三级的补助比例在逐年增加,而乡级补助比例在逐年下调。
5、住院率：2009年参合农民住院人次数达3812840次,7年间住院率从4.57%增长到8.26%,增长幅度较大。
6、住院补偿政策：对调查样本中补偿政策信息完整的71个县(市、区)农合补偿政策进行分析,并对这71个样本县2007年到2009年间的原始数据进行统计：起付线的高低与次均住院费用(r=0.8067,p=1)和次均补偿费用(r=0.6211,p=1)的高低有正相关关系,封顶线的高低与次均住院费用(r=0.0483,p=1)无相关关系、与次均住院补偿费用(r=0.1986,p=1)有正相关关系。
7、统筹基金受益面：虽然统筹基金补助受益面在2007年间有所下降,但基金效益整体呈上升趋势,受益面在逐年提升。最初2003年度的统筹基金补助受益面和住院补助受益面分别4.57%和2.80%,到2009年已经增加至32.65%和8.26%。
8、统筹基金受益度：2003年到2009年,湖南新农合住院补助受益度呈上升趋势,特别是在2008、2009两年间,增长幅度较往年明显增大。2003年的统筹基金补助受益度为26.75%,到2009年已经增加至41.63%,较2003年增长14.88个百分点。
9、趋势预测：通过残差灰色预测模型预测结果来看,参合率、次均住院补助费用、统筹基金补助受益面、住院补助受益面、住院补助受益度均呈上升趋势,而农民自费金额也将逐步下降,说明湖南省新农合将能够持续发展,新农合整体运行效益呈上升趋势。次均住院费用有增长趋势,未来三年将按2.757%、2.759%、2.761%的速率增长。
三)老年农民住院疾病谱研究
1、参合率：2006年-2010年湖南省65岁及以上老年人参加新农合的人数由664934人增加到2611754人,参合率由75.39%增加到95.37%。
2、住院率：2006年-2010年湖南省65岁及以上老年人住院人次由63254增加到514170人次,住院率由9.51%增加到19.69%。
3、疾病构成：湖南省老年人所患疾病以呼吸系统疾病最多,以2010年数据为例前十位疾病中,呼吸系统疾病占50.34%。按疾病分类分,2010年排在前十位的疾病依次是肺部感染、冠心病、慢性支气管炎、高血压、心绞痛、慢性支气管炎急性发作、脑梗塞、肺源性心脏病、脑梗死、肺炎。5年来前10位住院疾病略有变化,排在第一位的一直是肺部感染,冠心病心绞痛、高血压、肺炎、慢性支气管炎、脑梗死、冠心病六种疾病也一直位居前十位。
结论
1、湖南省新型农村合作医疗制度平稳运行。新农合制度实施以来,农民参合率稳步提高,财政补助大幅增加,资金足额筹集到位,新农合整体运行效益呈上升趋势,参合农民受益程度逐年提高。
2、新农合制度的实施促进了农村卫生事业发展。通过新农合制度费用补偿机制的动态调节,合理引导农民就医,有利于促进医疗卫生资源的优化分配,增强卫生服务的可及性,从一定程度上改变了农村卫生的现状。
3、影响基金运行效益的主要因素。补偿比例、起付线的高低是影响住院补助受益面的主要因素。补助受益度不一定与经济情况成正比,而与基金支出计划、补偿比例相关。补偿比例对新农合的受益水平和参合农民的择医就诊取向有较大影响。起付线对住院补助受益面的影响一般呈负相关,起付线越高则受益面越窄,起付线越低则受益面越宽。门诊统筹基金可有效扩大新农合的受益面。
4、新农合存在的主要问题。1)住院率有增长过快的趋势。新农合制度的实施在一定程度上激发了农民的医疗需求,但住院率有增长过快的趋势,已经超出了由于新农合制度本身激发出的医疗需求所带来的增长范畴。2)新农合病员、资金流向有变化。新农合病员、资金流向有由乡级医疗机构向县级医疗、省级医疗机构流动的趋势。
5、湖南省参合老年农民主要疾病。本次研究显示肺部感染、冠心病、慢性支气管炎、高血压、心绞痛、慢性支气管炎急性发作、脑梗塞、肺源性心脏病、脑梗死、肺炎等病是老年人易患的常见病种,对老年人健康危害较大。
6、新型农村合作医疗制度仍是一低水平保障制度。新型农村合作医疗制度是一农民自愿参加的互助共济的制度,还不是真正意义上的社会保障制度,它的特点是低水平、广覆盖,保障水平和保障程度是有限的,是农村医疗保障制度的初级阶段,是一种低水平的农村基本医疗保障制度。
Objective Analysis of Hunan Province, the new rural cooperative medical system (hereinafter referred to as the "new rural cooperative") to run the status quo, Hunan Province in2003-2009the new rural cooperative development trend of the longitudinal study, a comprehensive survey to acquire the relevant information, the Participatingthe fund raising, fund expenditures, the compensation of the five aspects and the operational benefits of the Fund in-depth analysis. An objective assessment of the new rural cooperative from the pilot application to the implementation process since the full implementation of the operational benefits of the Fund, the farmers really get the benefit, analyze and forecast the future trend of development of the new rural cooperative to explore problems in the new rural cooperative work method for the reasonable compensation scheme established by the regulatory regime for the rational allocation of health resources in Hunan Province, to promote the development of new rural cooperative medical health and to provide a basis.Hunan Province2006-2010participating elderly hospitalization data from the disease constitute the distribution of statistical analysis to understand the onset of disease prevalence and distribution characteristics, a clear onset of disease prevention and control work priorities, to provide for future population health interventionbasis.
Method The survey was conducted under the jurisdiction of13cities in Hunan Province, an autonomous prefectures and122counties (cities, districts) of all levels of the new rural cooperative agencies, designated medical institutions and the new rural cooperative Participating Farmers. The survey sampling, Hunan Province,2009the province of all counties (districts) and the new rural cooperative data, data analysis methods, using statistical analysis software-related data collection, collation and analysis. As follows:1) general statistical analysis of the status quo analysis of Hunan Province, the new rural cooperative of14cities and prefectures (Changsha City, Zhuzhou, Xiangtan, Hengyang, Shaoyang City, Yueyang, Changde City, Zhangjiajie, Yiyang City, Chenzhou City, Yongzhou, Huaihua City, Loudi City, Xiangxi state), the new rural cooperative medical information to cities and prefectures as a unit for statistical analysis. Statistical analysis software SPSS13.0, Excel, etc.;2) the years of2003-2009, the new rural cooperative development trends in the use of vertical contrast, the univariate analysis, trend prediction using residual gray forecasting model to predict;3) hospitalized elderly spectrum of disease distribution using the international classification of Diseases codes (ICD-10),2006to2010, before the new rural cooperative elderly hospitalized50patients for statistical analysis.
Result50,479,300of the agricultural population, the new rural cooperative medical care system has been fully covered in Hunan Province in2009.
I The Hunan NRCMS Analysis:
a. Participating:In2009, Hunan Province, the average participation rate to reach91.49%, which parameters together rate the highest for the Changsha City up to95.03%, minimum Loudi City,86.33%, Shaoyang City, Yongzhou, Changde City, Xiangxi state, Zhangjiajie CityHuaihua City, Loudi City half of the City, state Senate combined rate below the provincial average.
b. Fund-raising:In2009, the funding criteria of Hunan Province is100yuan/person. Individual farmers pay20yuan, the central financial subsidy of40yuan, the provincial government subsidy of24yuan, cities, counties two fiscal subsidies, government subsidies accounted for80%of the total amount of the new rural cooperative fund.
Hunan Province, the new rural cooperative fund raising from three sources:First, governments at all levels of financial subsidies for individual farmers to pay funds, social contributions. In2009, Hunan Province, the new rural cooperative plan to raise4,644,405,500yuan, the actual funding of4,784,828,200yuan, of which1.84billion yuan from the central budget funds, local property grant funds of1.86billion yuan (provincial finance1,177,573,400yuan, Municipal Finance336661600yuan, county finance352,431,100yuan), the urban and rural self-pay924million yuan of funds. Financial assistance is basically on time in full and in place to protect the new rural cooperative medical system to the smooth implementation.
c. Fund expenditure:2009, Hunan Province medical fund expenditures amounted to4740996000yuan, the co-ordinated fund expenditure4583221500yuan, accounting for96.67%of the total fund expenditure. The actual expenditures accounted for annual fund raising a total ratio of99.08%, of which Xiangtan city104.11%, Shaoyang100.20%, Changde105.81%, Yongzhou100.22%and Loudi103.56%, more than100%. In2009Hunan Province medical fund expenditure to hospitalization subsidy as the main form, including hospitalization subsidy fund expenditures accounted for87.20%, ambulatory grant expenditures accounted for3.92%, fixed hospital maternity benefits fund expenditures accounted for2.88%, serious special outpatient grant expenditures accounted for2.61%, subsidy fund expenditures accounted for0.26%.
4. Hospital compensation
1) hospitalization rates:in2009Hunan Province farmers in times reached38128400people, hospitalization rate8.26%. The provincial hospital hospitalization rate was0.56%, the rate of hospitalization for0.70%municipal hospital, county hospital hospitalization rate was2.66%, the rate of hospitalization for4.34%Township hospitals. From the inpatient rate distribution, the farmer sees a doctor the inpatient mainly concentrated in the county and township level two hospital.
2) hospital costs:2009, Hunan hospital for a total cost of9600715500yuan, the average hospitalization expenses for2518yuan. Which Loudi City, Changsha City, Xiangtan City, Shaoyang City, Hengyang city of5ground city, the average hospitalization expenses in provincial above average level, is the highest in Changsha for3183.40yuan; the average hospitalization expenses were lower than average level of the province are Yongzhou City, Zhuzhou City, Chenzhou City, Yueyang City, Yiyang City, Changde City, Zhangjiajie, Huaihua and Xiangxi, Xiangxi is the lowest is1780.03yuan.
Medical institutions of different levels in different levels of hospital costs,2009Hunan Province, city, county, township medical institutions at all levels of the average hospitalization expenses were9946.31yuan, 5583.41yuan,2689.71yuan and958.51yuan. Changde City, Shaoyang City, Yiyang City, Chenzhou City, provincial, municipal, township average costs are higher than the provincial average.
3) can be reported to cost:2009, Hunan province hospitalization expenses for a total cost of8075559300yuan, accounting for the total hospitalization expenses of84.11%times can be reported, the cost is2117.99yuan. May report the highest proportion of Changde city is87.41%, is the lowest in Changsha City for79.62%. Can report proportion is higher than the provincial average with the exception of Changde in Huaihua City, Yiyang City, and Chenzhou City, Xiangxi, Loudi City, Shaoyang City, Yueyang City, Hengyang city; below the provincial average also has the city of Yongzhou, Xiangtan City, Zhuzhou City, Zhangjiajie city.
2009Hunan Province, city, county, township medical institutions at all levels of hospital times can be reported fees were7327.65yuan,4478.41yuan,2378.86yuan and904.09yuan. Hengyang City, Yueyang City, Yongzhou Province, city, county, countryside four class are costs are lower than the average level of the province.
d. the hospital compensation:in2009Hunan province subsidy amount is3996798500yuan, province, city, county, township medical institutions at all levels of hospitalization reimbursement amount total hospitalization subsidy ratio was17.22%,14.54%,38.96%,29.18%.
2009Hunan province average average hospitalization subsidy costs1048.25yuan, province, city, county, township medical institutions at all levels of hospital are the amount of compensation in the order of2682.65yuan,1788.58yuan,1268.96yuan and582.38yuan, the proportion of subsidy is respectively26.97%,32.03%,47.18%,60.76%. Changsha City, Zhangjiajie city and Yiyang city of province, city, county, countryside four class are hospitalization subsidy ratio were lower than the provincial average; Yueyang City, Changde City, Yongzhou city and Xiangxi Province, city, county, countryside four class are hospitalization subsidy ratio were higher than the provincial average.
e. outpatient compensation:2009, Hunan started out-patient co-ordinate the pilot, farmers per person per year of average outpatient service fund compensation standards for the10-15yuan, special chronic out-patient co-ordinate the fund compensation standards for the5-10of average per capita per month. Start the out-patient co-ordinate the pilot county (city, area) for a total of58, of which11counties of Yongzhou city all start, Changsha City, Xiangtan city and Chenzhou city did not begin out-patient co-ordinate the pilot job. Out-patient co-ordinate trips8891560times total subsidy, subsidy179439600yuan.
f. Benefit of fund:In2009Hunan province average hospitalization benefit degree is41.63%, each city state hospitalization subsidy benefit is not balanced,14cities in7cities in the province the proportion of subsidy is above average, Changsha City, Shaoyang City, Yueyang city and other places City hospitalization subsidy level is relatively low. Although the regional funding levels are similar, but the compensation levels differ greatly, which grants the highest proportion of Changde city of46.22%, was the lowest in Changsha City is only36.46%, the lowest percentage in compensation and compensation with the highest proportion of area difference of nearly10percentage points.
g. Benefit from the surface of fund:In2009, the fund as a whole the average hospitalization benefits coverage is32.85%, each city state hospitalization subsidy benefit is not balanced, the highest for the city of Yiyang in83.60%, the lowest in Loudi city for12.12%, only Yiyang City, Yueyang City, Changde City, Zhangjiajie, Xiangtan, Huaihua6city in the province of above average yield surface.
Ⅱ.2003-2009in Hunan province new rural cooperative medical system development trend analysis
a. Participation:Hunan province the first batch of pilot work of new rural cooperative medical system from2003July officially began, so usually we will in2003July to2004December to the first operating year. The first operation year in new rural cooperative medical system covering only the agricultural population of3420000people, along with the new rural cooperative medical system is ceaseless and perfect, the coverage is expanding year by year. In2005the new Liling9pilot counties (city, area), covering the agricultural population of9120000people.2006pilot counties to count to43, covering the agricultural population of24635000people. In2007the new County Urban reached99, covering the agricultural population of47969000people. The implementation of complete2008province county urban reached122, implementation of the new rural cooperative medical system comprehensive coverage, to complete2009province participation rate is91.22%. From2003to2009, the Hunan medical participation rate has been on the rise, but still slightly lower than the average level of central area, and the national average level still has certain difference, a difference of2.97%.
b. Fund raising situation
Starting from2003-2009pilot to carry out in the round, Hunan NCMS financing level gradually upgrade:in2003the NCMS financing standard is30yuan/person, including the fiscal subsidy of20yuan, farmer burden10yuan;2006farmer individual pay is changeless, raise standards for50yuan/person; in2008the total funding standard was raised to80yuan/person, individual farmers to pay the amount still is10yuan of;2009funding standard continued to improve until100yuan/person, including financial subsidy standard is80yuan/person, individual payment standard also increased to20yuan/person; to complete2010province the NCMS financing standard is raised to140yuan per person per year, of which all levels of financial subsidies standards to120yuan per person per year. Provincial and municipal, county urban district each year to ensure that the financial subsidies in place in full and on time, financial subsidy funds have accounted for more than80%of the total amount of NCMS fund of central finance allowance, which accounts for about40%of main fund source.
c. fund expenditure
2003-2009years complete province overall fund utilization rate shows ascendant trend, followed by70%,80.94%,80.60%,88.82%,90.20%,103.62%, the province plans as a whole the average fund usage rate of94.43%. As of2009December, Hunan Province, the total subsidy number33219328person-time, pooling fund expenses for102252614000yuan. Fund expenditure is mainly used for hospitalization subsidy subsidize hospitalized childbirth, illness, quota special outpatient subsidies, subsidy, which cumulative hospitalization subsidy accounting for cumulative overall fund89.95%, fixed hospital maternity benefits accumulated fund expenditure accounted for2.45%, serious special outpatient subsidies or accumulated fund expenditure of2.71%, accumulative total subsidy fund expenditure accounted for0.76%.
Ⅲ Hospital compensation
a. the average hospitalization expenses:From2003to2009, the Hunan province overall hospitalization expenses level was slow ascendant trend, in2008reached2621.52yuan/passengers, a9.71%increase over2003-2009growth under control, cost relatively dropped somewhat2008less103.52yuan, down0.04%.
b. Average hospitalization subsidies:From2003to2009, Hunan's average hospitalization subsidy costs increase year by year, hospitalization subsidy level is rising, especially with the2008and2009to raise standards, the growth rate is also higher cost subsidy. In2003the hospital costs are subsidy amount is only639.18yuan, accounting for26.75%of the total cost, average hospitalization expenses in2009increased to1048.24yuan, the proportion of subsidy was elevated to41.63%.
c. Self cost:From2003to2009, although the farmer hospitalization expenses increased year by year, but the average cost of subsidies has been greater than the growth rate of inpatient cost growth, so the farmer pays part of the cost has been reduced, by2003,1750.28yuan to1469.75yuan reduction, at their own expense subsidy ratio decreased from73.25%to58.37%.
d. inpatient hospital level distribution:The province's hospitalization subsidy trips distribution in township health centers in most medical institutions at county level, the structure of medical assistance at the county level or above, is the least number of less, provincial medical organizations. From the beginning of2008in the provincial medical institution of agricultural patients is increasing, visiting rate increased from5.69%to6.77%. In2009the municipal medical treatment rate is reduced, the other three level medical treatment rates have improved, the patient began to have from the municipal medical institutions to the ends of diversion trends, namely to the provincial medical organizations, downward County, countryside two class medical institutions.
f. capital flows:Grant passengers flow and grant funding disproportionately, county subsidy proportion is the largest, the smallest proportion of municipal subsidies. New rural cooperative medical fund is mainly used for farmers in County, countryside two class medical institutions hospitalization subsidy costs, the amount of compensation for the overall amount of about70%. Capital flows from the point of view, the Hunan new policy changes gently, province, city and county level three the proportion of subsidy increases year by year, and the proportion of subsidy in cut each year.
g. hospitalization rate:2009peasants inpatients number to be amounted to3812840times, in7years the rate increased from4.57%to8.26%, growth range is bigger
h. the hospital compensation policy:On14city state of compensation policy information complete71counties (city, area) agricultural compensation policy were analyzed, and the71sample counties from2007to2009of the original statistical data:deductible level and average hospitalization expenses (r=0.8067, p=1) and time (compensation costs r=0.6211, p=1) or there is a positive correlation between the top line, the level of the average hospitalization expenses (r=0.0483,p=1) there is no correlation, and compensation are cost (r=0.1986, p=1) there is a positive correlation between. i. pooling fund benefit:Although the whole fund subsidy benefit in
2007years has declined, but the fund benefits the overall upward trend, benefit to promote in year after year. The initial2003year whole fund subsidy benefit and hospitalization subsidy benefit surface are respectively4.57and2.80%, and2009has been increased to32.65and8.26%.
j. pooling fund earning degrees:2003to2009, Hunan hospitalization subsidy benefit degree shows ascendant trend, especially in2008,2009in two years, the growth rate of a noticeably increases.2003fund subsidy benefit of26.75%, to2009already increased to41.63%, compared to2003increased55.63percentage points.
IV Investigation on disease spectrum of elderly hospitalized farmers
a. the participation rate:2006-2010in Hunan province in the elderly aged65and above in the new rural cooperative medical system number increased from664934to2611754, from75.39%to95.37%participating.
b. hospitalization rate:2006-2010in Hunan province in the elderly aged65and above by63254person-time inpatients to increase514170person-time, hospitalization rate from9.51%to19.69%.
c. disease:Disease system respectively to the respiratory system up to2010, data of the top ten diseases, respiratory system50.34%. According to the classification of diseases,2010in the top ten diseases were pulmonary infection, chronic bronchitis, coronary heart disease, hypertension, coronary heart disease angina, acute exacerbations of chronic bronchitis, cerebral infarction, pulmonary heart disease, cerebral infarction, pneumonia.5years before the10inpatients with slight variations, in the first row is always a lung infection, the rest has been among the top ten of angina pectoris of coronary heart disease, hypertension, chronic bronchitis, pneumonia, cerebral infarction.
Conclusion
Ⅰ. The Hunan province new rural cooperative medical system running smoothly.
The new rural cooperative medical system comprehensive coverage since, farmer participation rate rises steadily, financial subsidy increases considerably, funds raised in new rural cooperative medical system in full, the overall operation efficiency rise, the participants'benefit degree increase year by year, effectively alleviates the peasants'economic burden of disease.
Ⅱ. The new rural cooperative medical system has promoted the implementation of the development of rural health service.
The new rural cooperative medical system the cost of compensating regulation, reasonable guiding farmers cooperative medical system and medical treatment, the development of rural health service has formed a complementary, mutually reinforcing relationship. Patient flow changes conducive to promoting health and reasonable utilization of resources, enhance health services accessibility, from a certain extent changed the status quo of rural health.
Ⅲ. The main factors influencing fund operating efficiency.
Compensation ratio, deductible level is the main factor influencing hospitalization subsidy benefit. Subsidy level is not certain and economic situation is proportional, and fund spending plan, compensation ratio. Proportion of compensation for new rural cooperative medical system benefit level and farmers' choice of medical treatment orientation has great influence. Deductible on hospitalization subsidy benefit affecting the general was negatively related to pay lines, high benefit face more narrow, less deductible will benefit the wider. Compensation line cap affects new rural cooperative medical system to alleviate farmers'poverty caused by diseases, to play the role of.5, out-patient co-ordinate the fund can effectively expand the medical benefit, to relieve the pressure of outpatient medical costs, improve and consolidate the majority of farmers ' enthusiasm, has the very vital significance.
Ⅳ. The main problem.
A new type of rural cooperative medical system in the implementation of a certain extent of excitation of the farmer's medical needs, but the rate of hospitalization, hospitalization costs have fast growth trend, already exceeded due to the new rural cooperative medical system itself inspired the medical needs of the growing category, the presence of excessive medical risk.
Ⅳ Hunan Province, farmers'main diseases.
This study showed that pulmonary infection, chronic bronchitis, coronary heart disease, hypertension, coronary heart disease angina, acute exacerbations of chronic bronchitis, cerebral infarction, pulmonary heart disease, cerebral infarction, pneumonia and other diseases that predispose the elderly to common diseases on the health of the elderly, great harm. The new rural cooperative medical system is a farmer to participate in voluntary mutual aid system, not the true sense of the social security system, it is characterized by low level, wide coverage, so the security level and the security level is limited. With the city's basic medical insurance, new rural cooperative medical security strength is lesser, regulations to be sound,
Ⅵ. New rural cooperative medical system is still a low level security system.
management needs to be further standardized, efforts need to be further more. Can say, the new rural cooperative medical system is the rural medical security system in the primary stage, is a low level of rural basic medical security system. In this sense, the new cooperative medical system is in a transition period from junior to senior development, need various government support and attention, governments at all levels will also be in the implementation of the new rural cooperative medical processes play a more important role.
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