上海市儿童医疗保险制度比较分析

Comparative analysis of children's medical insurance system in Shanghai

目的分析上海市儿童医疗保险制度的现状,寻找改进和完善的途径。方法系统收集和分析上海市儿童医疗保险政策,并与北京市、天津市和重庆市的儿童医疗保险政策(包括筹资标准、起付线、报销比例和封顶线等)进行比较。对320例儿童白血病、恶性肿瘤及先天性心脏病病例的医疗费用报销情况进行回顾性分析。结果上海市儿童医疗保险主要由"双保险"构成:少儿住院互助基金及中小学生和婴幼儿的城镇居民基本医疗保险。与其他年龄段城镇居民基本医疗保险相比,儿童的城镇居民基本医疗保险筹资标准相对较低,门诊报销比例相当;住院报销比例为50%,低于60岁以上人群的报销比例。与其他直辖市比较,上海市儿童"双保险"的个人缴费水平最高(140元),但报销没有设置封顶线。病案分析显示,白血病和恶性肿瘤化疗病例的总体报销比例为87.76%,先天性心脏病病例的总体报销比例为88.18%,均低于"双保险"情况下住院100%的理论报销水平。结论上海市儿童医疗保险筹资模式尚未与国民经济发展水平建立有机联系;贫困儿童重大疾病的医疗救助制度有待完善;理论保障水平与实际保险情况不尽吻合,儿童医疗保险的保障水平值得关注与提高。

Objective To investigate the current status of children's medical insurance system in Shanghai,and find out ways to improvement. Methods Relevant policies of children's medical insurance in Shanghai were systematically collected and analysed,and comparisons were made with those in Beijing,Tianjin and Chongqing on financing,deductibles,reimbursement proportions and cap lines.Reimbursements of medical expenses of 320 children with leukemia,malignancies and congenital heart diseases were retrospectively analysed. Results Children's medical insurance in Shanghai was 'double insurance',which contained Children's Hospitalization Fund and Basic Medical Insurance for Urban Residents of school students and infants.Compared with the other age groups,the financing of children's Basic Medical Insurance for Urban Resident was relatively lower,the outpatient reimbursement rate was roughly equal,while the hospital reimbursement rate for children(50%) was less than that of people over the age of 60.Compared with the other municipalities,the individual financing of children's 'double insurance' in Shanghai(140 RMB) was the highest,but the reimbursement cap line was not set.Through case analysis,it was found that the actual reimbursement rates of medical expenses of children with leukemia and malignancies(87.76%) and congenital heart diseases(88.18%) were lower than the theoretical level(100%). Conclusion The financing of children's medical insurance in Shanghai has not yet been established organic links with economic development.There is room for improvement in the medical aid system for poverty-stricken children with serious illness.The reimbursement rate of children's medical insurance is not in line with the theoretical level,and needs to be enhanced.