New cooperative medical scheme decreased financial burden but expanded the gap of income-related inequity: evidence from three provinces in rural China.
New cooperative medical scheme decreased financial burden but expanded the gap of income-related inequity: evidence from three provinces in rural China.
复制标题
DOI：
10.1186/s12939-016-0361-5
复制
发表时间：
2016-05-04
影响因子：
4.8
通讯作者：
Wang J
中科院分区：
文献类型：
--
作者：
Ma J;Xu J;Zhang Z;Wang J
在中国，通过保险计划补贴医疗费用对于克服医疗保健的经济障碍和避免患者的高额医疗支出至关重要。健康保险可以通过减少自费支付来降低财务风险，但不能保证保障权益。2008年以来，随着新型合作医疗融资规模和覆盖面的扩大，修订后的新型合作医疗财政负担保障政策的有效性和公平性有待进一步评估。2011年在浙江、湖北、重庆三省采用多阶段分层随机抽样的横断面入户调查方法。全国人口统计调查共对1525户家庭进行了分析。通过比较医疗服务利用和医疗支出的变化，以及医保实施前后灾难性医疗支出（CHE）发生率及其浓度指数（CIs）的变化，分析医保的保障效果和保障公平性。即使在新农合报销后，中国低收入农村居民的医疗经济负担仍然非常高，原因是OOP支付过高。在湖北省，最贫困的五分之一家庭的年度支出几乎相同。甚至比他们在重庆市的年度支出还要高。门诊和住院服务的有效报销比例远低于新农合计划最初设计的名义报销比例。新农合报销后，三省的CHE患病率均相当高，ci绝对值甚至高于报销前，说明不公平现象被夸大。政策制定者应进一步修改农村新农合政策。可通过扩大新农合的药品目录和福利包检查目录，缩小名义报销比例与有效报销比例之间的差距，降低高OOP支付。通过监测医疗服务提供者和患者的过度需求，将医疗服务提供者按服务收费的支付方式转变为前瞻性支付制度，控制医疗支出的增长。应通过修改新农合的累退性融资，并提供额外的财政援助和政府报销，保护农村弱势居民的服务可及性和可负担性。
Subsidizing healthcare costs through insurance schemes is crucial to overcome financial barriers to health care and to avoid high medical expenditures for patients in China. The health insurance could decrease financial risk by less out-of-pocket (OOP) payment, but not promise the protection equity. With the growth of New Cooperative Medical Scheme (NCMS) financing and coverage since 2008, the protection effectiveness and equity of the modified NCMS policies on financial burden should be further evaluated. A cross-sectional household survey was conducted in Zhejiang, Hubei, and Chongqing provinces by multi-stage stratified random sampling in 2011. A total of 1,525 households covered by the NCMS were analyzed. The protection effectiveness and protection equity of NCMS was analyzed by comparing the changes in health care utilization and medical expenditures, and the changes in the prevalence of catastrophic health expenditure (CHE) and its concentration indices (CIs) between pre- and post-NCMS reimbursement, respectively. The medical financial burden was still remarkably high for the low income rural residents in China due to high OOP payment, even after NCMS reimbursement. In Hubei province, the OOP payment of the poorest quintile was almost same as their households’ annual expenditures. Even it was higher than their annual expenditures in Chongqing municipality. Effective reimbursement ratio of both outpatient and inpatient services were far lower than nominal reimbursement ratio originally designed by NCMS plans. After NCMS reimbursement, the prevalence of CHE was considerably high in all three provinces, and the absolute values of CIs were even higher than those before reimbursement, indicating the inequity exaggerated. Policymakers should further modify NCMS policy in rural China. The high OOP payment could be decreased by expanding the drug list and check directory for benefit package of NCMS to minimize the gap between nominal reimbursement ratio and effective reimbursement ratio. And the increase in medical expenditures should be controlled by monitoring excess demand from both medical service providers and patients, and changing fee-for-service payment for providers to a prospective payment system. Service accessibility and affordability for vulnerable rural residents should be protected by modifying regressive financing in NCMS, and by providing extra financial aid and reimbursement from government.