内蒙古某三级甲等医院各医保类别住院患者直接医疗经济负担分析

Discharged patient direct disease burden analysis under different health insurance scheme in a top tertiary hospitals in Inner Mongolia

目的:通过分析不同医保类别住院患者直接医疗经济负担,为合理使用医保基金,有针对性地制定缓解群众看病贵、负担重问题的卫生政策提供新思路与依据;为评价城乡医保制度整合后,对农村居民疾病经济负担的影响提供基线数据。方法:从样本医院信息管理系统内提取2015-2016年各医保类别住院患者的医疗费用与疾病信息,依据ICD-10国际疾病分类法对住院患者疾病信息进行分类,统计依据为住院患者第一诊断信息。结果:2015年与2016年各医保类别住院患者人均住院总费用、目录外费用、自付费用差异均具有统计学意义(P<0.001)。2015-2016年各医保类型住院患者人均总费用、自付费用居前两位主要为肿瘤与循环系统疾病,城镇职工肿瘤住院患者人均总费用最高,循环系统疾病人均住院总费用居首位的为新农合住院患者。肿瘤、循环系统疾病人均自付费用新农合住院患者高于城镇职工与城镇居民患者,居首位。结论:医保应发挥好医、保、患三方关系中的纽带作用,加强监管医疗机构医疗行为,同时应多方共筑多层次医疗保障体系,有效降低群众直接医疗经济负担。

Objectives： To provide new ideas and evidence on rational use of medical insurance fund, effective smooth the inaccessible and unaffordable of health utilization by analyzing the direct hospitalization burden under different health insurance scheme. And, to provide baseline data for assessing the impact of direct disease burden of rural residents after urban and rural health insurance system integration. Methods： Medical expenses and disease of hospitalized patients in the sample hospitals were collected from information management system from 2015 to 2016. The information of hospitalized patients was classified according to the ICD-10 and the statistics were based on the first Diagnostic information. Results： There were significant differences（P〈0.001） in the average total hospitalization cost, the out-of-course expenses and out of pocket expenses of hospitalized patients in 2015 and 2016 between difference health insurance schemes. The top 2 diseases of average cost and average out of pocket payment are cancer and circulatory system disease. Patient who is covered by urban employee health insurance scheme got a highest cost on the average cost of cancer while patient with a NCMS got a highest cost on circulatory system disease. The out of pocket payment of cancer and circulatory system disease in rural is higher than that of urban. Conclusions： It is considered that health insurance department needs to play a role on coordinate the relationship among health insurance, patient and hospital, monitoring hospital behavior and establish multi-protect channel to effectively reduce patient＇s direct disease burden.