基于医保视角的超大城市慢性病住院负担与应对策略——以中部W市为例

Burden of hospitalization and countermeasures for chronic diseases in megacities from the perspective of medical insurance:A case study of W city in central China

目的:以W市为例研究慢性病住院患者所致医保支出的分布特征,并测算基本医疗保险的实际报销水平和患者的自付水平,为完善医疗保险慢性病政策提供决策依据。方法:依据ICD-10编码,从W市医保局的系统数据中提取主要慢性病患者的住院信息并进行分类整理。结果:2018年慢性病对职工医保和城乡居民医保所带来的住院负担分别达到了40.6亿元和10.7亿元。其中,两种共病患者和中老年人是医保支出占比最高的群体,而三级医院则是医保支出流向最多的机构。虽然医保基金的实际报销比例随着慢性病患者年龄的增大而呈上升趋势,但是患者自付水平却没有稳定下降。结论:慢性病在很大程度上加重了医保基金的支付压力,应该转变传统的医保管理理念,强化慢性病门诊保障力度,加强对于医保基金的监管,并优化慢性病患者的医保待遇结构。

Objective:Taking W City as an example,the distribution characteristics of medical insurance expenditures caused by hospitalized patients with chronic disease were studied,and the actual reimbursement level of medical insurance and the out-of-pocket payment level of patients were measured,so as to provide a decision-making basis for improving medical insurance policies for chronic diseases.Methods:According to ICD-10 codes,the hospitalization information of patients with major chronic diseases was extracted from the system database of Healthcare Security Administration in W city and sorted into categories.Results:The financial burden caused by hospitalized patients with chronic diseases on urban employee basic medical insurance and urban-rural resident basic medical insurance reached 4.06 billion yuan and 1.07 billion yuan respectively.Among them,patients with two comorbidities and middle-aged and elderly people are the groups with the highest proportion of medical insurance expenditure,while tertiary hospitals are the institutions with the largest flow of medical insurance expenditure.Although the actual proportion of reimbursement from the medical insurance fund tended to increase with the age of inpatients with chronic diseases,the level of out-of-pocket payments by inpatients has not steadily decreased.Conclusions:Chronic diseases have largely increased the payment pressure of medical insurance funds and it is necessary to change the concept of traditional health insurance management,strengthen the protection of chronic disease outpatient clinics,enhance the supervision of medical insurance funds,and optimize the structure of medical insurance benefits for patients with chronic diseases.