四川省城乡居民大病保险合规医疗费用界定研究(一)——2011年城乡居民就医诊疗及医疗保险报销情况分析

Research on the Definition of Compliance Medical Costs in Serious Illness Insurance of Ubran and Rural Residents in Sichuan Province( Ⅰ)——Analysis of Hospitalization and Medical Insurance Reimbursement of Ubran and Rural Residents in 2011

目的:为进一步提高大病保险合规医疗费用的报销水平提供参考。方法:收集四川省近年来的卫生统计数据,分析该省城乡居民就医诊疗总体情况及2011年医疗保险报销情况。结果:2007-2011年,该省总诊疗人次和住院人数增幅较大,各类医院收治的患者人数总体上多于乡镇卫生院,且差异逐年增大;民众就医向优质医疗资源集中,等级越高的医院病床使用率越高,且民营医院的病床使用率低于其他医院。2011年,等级医疗卫生机构人均医药费用明显高于基层医疗卫生机构人均医药费用,且三级医疗卫生机构人均医药费用明显高于其他医疗卫生机构。2011年,该省城镇居民"医保"和"新农合"实际报销比例分别为52.07%、51.89%,其中医疗费用超过5万元的患者的实际报销比例分别为45.58%、42.42%。结论:有必要深入剖析三级医疗卫生机构住院费用构成及变化情况,科学合理地将部分个人自付费用纳入大病保险合规医疗费用范围,以利于减轻民众就医负担。

OBJECTIVE：To provide reference for further improvement of compliance medical cost reimbursement of serious illness insurance in our province.METHODS：The general trend of outpatient and inpatient and general situation of medical insurance reimbursement in 2011 were analyzed according to statistical data of our province.RESULTS：Total number of outpatient visits and inpatient in our province increased significantly during 2007-2011;the number of patients in vaious hospitals were generally higher than in town hospitals,with an increasing difference year by year.People tend to choose big hospitals with a non-selective difference;the higher the grade of hospital was,the more hospital beds was used;the utilization ratio of hospital beds in private hospital was lower than in other hospital.Health data in 2011 showed that medical costs per capita of second or third level hospitals were far higher than those of basic ones;medical costs per capita of third level hospitals were significantly higher than second level and primary hospitals.Reimbursement rates of＂Medical Insurance＂and＂New Rural Cooperative Medical Scheme＂（NRCMS） were 52.07% and 51.89%;reimbursement rates of patients who had mecial expenditure over 50 000 yuan were 45.58% and 42.42%.CONCLUSIONS：It is necessary to deeply analyze the composing and variation of inpatient costs in third level hospitals.Medical burden of the public can be relieved by including out-of-pocket health care expenditures into compliance medical cost of serious illness insurance reasonably.