城乡医保整合对农村中老年人基层就诊行为的影响研究——基于健康差异的分析视角

The impacts of the integrated medical insurance system on the primary care visit behaviors of rural middle-aged and elderly people:From the perspective of health differences

引导农村中老年人理性就医,提高其医疗服务利用效率对实现乡村振兴和“健康中国”有重要的现实意义。基于健康差异的分析视角,利用2013—2018年中国健康与养老追踪调查(CHARLS)数据,运用聚类分析法、多时点双重差分模型和工具变量法,从门诊与住院两个方面分析患者就诊选择的现实状况与特征,探讨城乡医保整合对农村中老年人基层就诊行为的影响。结果表明,农村中老年人门诊和住院基层就诊的比例分别为63.2%和44.3%,整合地区患者就近就医的比例均高于未整合地区,且随着时间的推移,不同健康状况患者的就医选择趋于理性。城乡医保整合有效引导了农村中老年门诊与住院患者就近就医,其中对门诊患者就近选择基层就诊产生更大程度的促进效果。城乡医保整合有助于提升优良健康状况门诊患者就近就医的概率,能够有效引导中等健康状况住院患者就近就医,但显著弱化不健康的住院患者选择基层就诊的倾向。随改革实施时间的推移,城乡医保整合对农村中老年人就近就医的促进作用不断增强。此外,一档制整合模式对农村中老年人基层就诊的引导效果优于多档制整合模式。据此,提出基于健康差异细化城乡居民医疗保险的补偿政策,提升农村基层医疗服务质量,逐步推进城乡居民医疗保险一体化进程等政策建议。

It is of great practical significance to guide rural middle-aged and elderly people to seek medical treatment rationally and to improve the efficiency of their medical service utilization to achieve rural revitalization and"healthy China"'.From the perspective of health differences and based on a data of China Health and Retirement Longitudinal Study(CHARLS)from 2013 to 2018,this paper analyzed the reality and the characteristics of patients'medical choices and discussed the impacts of the Integrated Medical Insurance System(IMIS)on the primary health care visit behaviors of rural middle-aged and elderly people from both aspects of outpatients and inpatients by the cluster analysis,the timevarying DID and the instrumental variable methods.Results show that the proportion of outpatient and inpatient primary care for the middle-aged and elderly in rural areas was 63.2%and 44.3%,respectively.The proportion of patients in the integrated areas who went to the nearest hospital was higher than that in the non-integrated areas,and with the passage of time,the medical choice of patients with different health conditions tended to be rational.The IMIS can effectively guide the outpatients and inpatients of rural middle-aged and elderly to seek medical treatment nearby,which has a greater significant impact on outpatients'choice.The IMIS can significantly improve the probability of outpatients with good health level to seek medical treatment nearby and guide inpatients with medium health conditions to seek medical treatment nearby.However,the willingness of unhealthy patients to select primary health care services is significantly weakened.The policy effect of the IMIS on rural middle-aged and elderly people's access to medical care nearby has been increasing over time with the implementation of the reform.In addition,the"single system,single-standard"model can more effectively guide patients to select primary health care services than"single system,multi-standard"model.Therefore,this paper suggests:refining the compensation policy for medical insurance for urban and rural residents based on health differences,improving the quality of rural primary care services,and gradually promoting the integration process of medical insurance for urban and rural residents.