城乡居民大病保险的精准性补偿方案研究--以河南省为例

Researches on the Precision Compensation Scheme of Urban and Rural Residents'Critical Illness Insurance Sampled with Henan Province

目的:分析城乡居民大病保险补偿的精准性,为有力缓解因病致贫、因病返贫问题以及有效提升重特大疾病保障水平提供参考。方法:以需求为导向对城乡居民大病保险的补偿方案进行设计,构建灾难性医疗支出发生率测算模型以及灾难性医疗支出平均差距和相对差距测算模型,较为全面地反映灾难性医疗支出的发生情况和严重程度,以河南省为例对模型进行应用。结果:(1)由于人口和政策因素,现有补偿方案下河南省城乡居民大病保险难以精准地满足低收入群体需求,其灾难性医疗支出发生率、平均差距和相对差距远高于其它收入群体。(2)根据年龄与住院史结合调整的城乡居民大病保险方案测算分析结果显示,所有收入群体的灾难性医疗支出平均差距和相对差距均有小幅下降;根据个人年收入分层制定的城乡居民大病保险方案分析结果显示,低收入群体的平均差距和相对差距大幅下降,其他各收入群体有所上升。(3)将年龄、住院史与收入结合形成新的方案测算结果显示,所有收入群体的灾难性医疗支出平均差距和相对差距均有明显下降,低收入群体下降幅度最大,新方案能够综合前两种方案的效果。结论:基于年龄、住院史与收入结合的新方案能够有效降低低收入群体的灾难性医疗支出风险,在调整补偿方案时采取渐进式的方法,首先从报销比例入手,根据年龄与住院史制定差异化的报销比例,后期根据实施效果进一步采取年龄、住院史与收入结合的方案,较好地实现大病保险补偿的精准性。

Objective To analyze the precision of compensation for urban and rural residents'critical illness insurance and pro-vide reference for effectively alleviating the problem of poverty caused by illness and returning to poverty due to illness,and effec-tively improving the level of protection for major diseases.Methods The demand-oriented compensation scheme of urban and rural residents'critical illness insurance was designed,and the calculation model of the probability of catastrophic medical expenditure and the average gap and relative gap of catastrophic medical expenditure were constructed to comprehensively reflect the probability and severity of catastrophic medical expenditure,which was applied in Henan Province.Results Due to the demographic and poli-cy factors,the urban and rural residents'critical illness insurance in Henan Province under the existing compensation scheme was difficult to accurately satisfy the needs of low-income groups.The probability,average gap and relative gap of catastrophic medi-cal expenditure were much higher than other income groups.According to the calculation and analysis of urban and rural residents'critical llness insurance scheme adjusted according to the combination of age and hospitalization history,the average gap and rel-ative gap of catastrophic medical expenditure of all income groups had decreased slightly.According to the analysis of the urban and rural residents'critical illness insurance scheme formulated according to the annual income stratification of individuals,the av-erage gap and relative gap of low-income groups had declined significantly,while other income groups have increased.Combi-ning with age,hospitalization history and income,the average gap and relative gap of catastrophic medical expenditure of all in-come groups had decreased significantly,and the low-income group had the largest decline.The new scheme can integrate the effects of the other two schemes.Conclusion The new scheme based on the combination of age,hospitalization history and income can effectively reduce the risk of catastrophic medical expenditure of low-income groups.A progressive approach should be a-dopted when adjusting the scheme.Firstly,starting from the reimbursement ratio,the differential reimbursement ratio is formula-ted according to the age and hospitalization history.In the later stage,according to the implementation effect,the scheme of com-bining age,hospitalization history and income is further adopted to better achieve the precision of the compensation of urban and rural residents'critical illness insurance.