發(fā)布時間：2018-05-27 06:31

  本文選題：新型農村合作醫(yī)療制度 + 制度研究��； 參考：《復旦大學》2013年博士論文

【摘要】：研究背景 農民作為“三農”問題中的首要問題,也為核心問題,其健康是關系到我國社會發(fā)展的根本問題。醫(yī)療保障制度則為維護農民健康,發(fā)揮著非常關鍵作用。我國農村的醫(yī)療保障制度發(fā)展經歷了漫長而曲折的探索過程,從上世紀60、70年代的輝煌,到80、90年代的衰退,導致95%以上的農民又回到“誰看病、誰掏錢”的自費醫(yī)療老路,許多農民因無力承擔醫(yī)療費用而無法獲得基本醫(yī)療服務,因病致貧、因病返貧現象嚴重。為解決我國農村居民的醫(yī)療保障問題,2002年中央政府提出,建立以大病統(tǒng)籌為主的新型農村合作醫(yī)療制度(新農合)。2003年起,新農合開始試點,至2012年底,全國參合農民達8.05億,參合率98%。新農合的迅猛發(fā)展,取得了明顯效果,保障范圍與保障水平不斷提高,但同時仍有不少問題妨礙著制度的健康發(fā)展。如何保證新農合的可持續(xù)發(fā)展是制度所面臨的首要問題,也是核心問題。通過文獻復習了解到,較多已有研究是從某個方面或某個角度對新農合制度展開研究,而從新農合制度各個主體的角度,并結合社會經濟環(huán)境,對新農合制度本身的籌資、補償支付、監(jiān)管等各個部分進行分析,探討新農合制度可持續(xù)發(fā)展的系統(tǒng)綜合性研究則相對較少。因此,本論文期望從可持續(xù)發(fā)展的視角,以新農合制度為研究對象,通過理論與實證的系統(tǒng)綜合分析,探尋影響新農合發(fā)展的制度內外因素,提出新農合制度可持續(xù)發(fā)展的政策建議。 研究目標 基于可持續(xù)發(fā)展視角,通過對新農合制度的籌資、補償、監(jiān)管以及制度外環(huán)境的系統(tǒng)綜合分析,以期為推進新農合制度從“制度建立”向“質量提升”轉變,促進新農合制度可持續(xù)發(fā)展提供思路和政策建議。具體目標： 1從可持續(xù)發(fā)展視角,對合作醫(yī)療制度的發(fā)展歷程進行回顧分析,探討成功與失敗的原因,總結其經驗教訓,為新農合制度的健康持續(xù)發(fā)展提供借鑒。 2從可持續(xù)發(fā)展視角,利用相關理論對新農合制度本身及其制度環(huán)境進行理論分析,探索實現新農合制度可持續(xù)發(fā)展的相關因素。 3利用全國新農合制度運行資料,描述新農合制度的實施狀況,分析新農合制度可持續(xù)發(fā)展存在的問題。 4利用我國西部某省三縣新農合制度實施的案例資料,分析其新農合制度發(fā)展過程中的運行狀況以及存在的問題,探討影響新農合制度可持續(xù)運行的相關因素。 5綜合理論及實證案例分析結果,提出實現新農合制度可持續(xù)發(fā)展的政策建議。 研究方法 1資料來源 (1)文獻資料 通過中國知網、OVID等專業(yè)文獻數據庫以及Google學術搜索引擎,以“新型農村合作醫(yī)療”“可持續(xù)”"new cooperative medical scheme""sustainable development"“集體化時期合作醫(yī)療”“傳統(tǒng)合作醫(yī)療”等為主題詞／關鍵詞進行組合檢索合作醫(yī)療研究相關文獻。 收集自2002年以來中央政府出臺的新農合相關政策文件,以了解新農合制度的政策進展及實施情況。 (2)現有宏觀數據資料 收集2006-2010年中國統(tǒng)計年鑒、中國衛(wèi)生統(tǒng)計年鑒及2006-2010年全國新農合信息統(tǒng)計手冊。 (3)案例資料 本研究收集的案例來自于歐盟資助項目“在中國和越南建立公平性和可持續(xù)性農村健康保障制度研究”。該項目根據新農合實施情況、兼顧地理分布和經濟水平以及當地政府自愿參與研究的原則,選取寧夏回族自治區(qū)中寧縣、青銅峽市和永寧縣3個縣(市)作為研究現場,于2006年開展新農合基線調查,調查方法包括定量調查、定性調查和現有資料收集,調查對象包括農民、衛(wèi)生服務提供者、新農合管理者、行政決策者。之后根據調查結果設計新農合干預方案,并自2007年1月起在3個項目縣(市)進行實施,于2008年開展新農合終末調查,調查對象與方法同基線調查。 2研究方法 (1)系統(tǒng)分析法 新農合制度建設是一項復雜的系統(tǒng)工程,涉及到各級政府職能部門,醫(yī)療衛(wèi)生機構、以及農村居民等多個主體,并且新農合制度是整個社會保障制度的一個子系統(tǒng),而社會保障制度又是整個社會的一個子系統(tǒng)。因此,新農合制度的建立和完善,不僅取決于新農合本身的制度設計,而且受到整個國家的政治、經濟、文化等社會環(huán)境因素的影響。本研究采用系統(tǒng)分析法,結合多個主體的視角,對制度本身和外部環(huán)境進行綜合系統(tǒng)分析,探討影響新農合制度健康持續(xù)發(fā)展的相關因素。 (2)歷史分析與比較分析 本研究通過回顧合作醫(yī)療制度發(fā)展歷程,從可持續(xù)發(fā)展視角,剖析其制度的自身設計及制度環(huán)境,探討其成功和失敗的經驗教訓。將新舊合作醫(yī)療制度發(fā)展進行比較分析,揭示其中差異,為當前新農合制度可持續(xù)發(fā)展提供啟示。 (3)理論分析和實證分析 本研究基于可持續(xù)發(fā)展視角,運用制度經濟學、福利經濟學、衛(wèi)生經濟學及社會保障等理論對新農合制度設計、運行機制進行理論分析,并結合全國新農合制度運行數據以及寧夏回族自治區(qū)三個縣案例的實證分析,為推進新農合制度可持續(xù)發(fā)展提供科學證據。 (4)現有資料分析與現場調查研究 本研究通過查閱和梳理合作醫(yī)療相關的專業(yè)文獻,了解合作醫(yī)療制度已有的研究成果；通過收集政府有關新農合制度發(fā)展的政策文件,了解國家政府對新農合發(fā)展的方針政策；通過收集全國新農合運行數據,分析新農合實施情況及存在問題。 本研究的案例資料中,在寧夏3個項目縣分別展開了現場調查,包括機構的定量調查以及對供方、需方和管理方的定性調查,收集了3個項目縣新農合的開展情況以及供方、需方和管理方對新農合的看法與建議等現場資料,為深度分析提供基礎。 (5)定性研究與定量研究 本研究案例分析中,采用定性與定量相結合的研究方法。對寧夏3個項目縣新農合運行的相關數據進行定量分析,并結合對3個項目縣的供方、需方及管理方的定性訪談,綜合分析寧夏項目縣新農合可持續(xù)發(fā)展的現狀和問題。 研究結果 1農村合作醫(yī)療制度發(fā)展歷程回顧分析主要結果 舊的農村合作醫(yī)療制度是建立在集體經濟基礎上,依托人民公社,依靠低成本的醫(yī)療服務供給系統(tǒng),滿足了當時農民的基本醫(yī)療需求,提供了低水平的醫(yī)療保障,雖然制度安排本身存有缺陷,但由于當時領導者的高度提倡,國家政策傾斜,形成的強大政治支持環(huán)境,高度行政集權,使得缺陷沒有明顯暴露,達成某種均衡狀態(tài),制度得到建立與發(fā)展。 但實質上,社會發(fā)展中遇到的問題如果都是集聚社會所有資源去解決的話,那可能就沒有不能解決的問題,但在現實中,這種狀況只可能是短期行為,不具有可持續(xù)性。上世紀70年代末農村經濟體制改革,我國的社會經濟環(huán)境和醫(yī)療衛(wèi)生服務體系發(fā)生了巨大的變革,這種均衡狀態(tài)被打破,使得合作醫(yī)療制度迅速走向衰退。 可見,制度發(fā)展正如經濟發(fā)展一樣,如果它脫離制度環(huán)境,無論是超越還是滯后于環(huán)境的發(fā)展,制度都是難以持續(xù)的,這正是可持續(xù)發(fā)展內涵核心,強調共同協(xié)調發(fā)展。 2理論分析主要結果 新農合制度是具有中國特色的初級社會醫(yī)療保險制度,政府在新農合制度建設和發(fā)展中應承擔主導責任,包括組織引導、制度規(guī)劃、財政支持、管理監(jiān)督與立法責任； 新農合制度籌資標準設計應考慮與農村居民的人均年收入、人均年醫(yī)療費用支出以及政府財政收入相匹配。各級政府籌資責任應更加明確,尤其是中央政府和省級政府應承擔起更多責任； 隨著新農合籌資水平的不斷提高,新農合補償模式可向福利風險型轉變,補償方案設計應考慮當地的經濟、醫(yī)療服務體系及醫(yī)療服務供給者的特點、農民的消費特點等制度外環(huán)境因素,并注意與其他相關制度的銜接。 構建多元化混合支付體系,是當前控制醫(yī)療費用迅速上漲,保持新農合基金平衡的有效措施。 衛(wèi)生部門作為新農合的主管部門,其雙重身份一定程度上制約了其執(zhí)行力,影響管理效果,可以考慮逐步整合社會保障部門資源,利于節(jié)約管理資源。 農村地區(qū)的城鎮(zhèn)化、人口老齡化、疾病譜變化、醫(yī)療保障需求的多樣化等問題給未來新農合發(fā)展帶來挑戰(zhàn),城鄉(xiāng)一體化的醫(yī)療保障體系亟待建立。 3全國新農合運行現況分析主要結果 全國新農合制度發(fā)展迅速,覆蓋面不斷擴大,2011年農民參合率己達97.5%,全國農村基本建立新農合制度,新農合籌資水平也逐步提高,已由2006年的人均52元增加到2011年的246元,新農合的受益面及受益水平不斷提升,參合農民人均補償額由2006年的38元上升到2011年的206元,人均受益次數則由2006年的0.66上升到2011年的1.58。但同時仍然存在籌資水平相對較低,籌資來源有待優(yōu)化,補償水平偏低等問題,故在今后新農合發(fā)展中,中央財政支持力度可進一步加大,農民個人籌資責任適當加強,個人繳納額度可適當提高,更好發(fā)揮集體經濟資助的作用,不斷提高新農合補償水平和保障能力。 4寧夏三縣新農合案例分析主要結果 2006-2008年寧夏3項目縣(市)新農合籌資標準逐年提高,個人繳費從每年10元提高到20元,各級政府補助從40元提高到80元,個人繳費占農民年人均純收入的比重均小于0.5%。農民參合意愿顯著提高,參合率逐年上升,2009年3項目縣(市)參合率都超過90%,在增加補償比例的前提下,農民愿意提高個人繳費額度。 2005-2007年寧夏3項目縣(市)新農合實行門診家庭賬戶與住院統(tǒng)籌相結合的補償模式,隨著新農合制度發(fā)展及其社會環(huán)境的變化,2008年開始,寧夏3項目縣逐步轉變門診補償模式,門診統(tǒng)籌逐步取代門診家庭賬戶。 2005-2008年寧夏3項目縣(市)每年進行住院補償方案調整,降低住院起付線,取消費用分段,提高住院補償比例,提高封頂線；3個項目縣(市)住院補償人次和受益率均逐年提高,但農民疾病經濟負擔仍較重,尤其是大病負擔。 總體而言,2006-2008年寧夏3項目縣(市)農民住院就診趨向選擇縣級醫(yī)院,鄉(xiāng)鎮(zhèn)衛(wèi)生院缺乏一定吸引力�？赡苡捎谧≡貉a償方案的不同設計,3項目縣(市)住院流向變化呈現不同趨勢。同期,不同醫(yī)療機構次均住院費用呈現上升趨勢,對醫(yī)療機構的費用控制缺乏科學有效監(jiān)管手段,加之管理部門自身監(jiān)管能力的不足,使得監(jiān)管效果有限。 政策建議 1強化政府主導責任,明晰各級政府職責內容 2建立穩(wěn)定長效的籌資機制,逐步提高新農合統(tǒng)籌層次 3繼續(xù)大力推進門診統(tǒng)籌,制定科學合理的補償方案 4加快開展支付方式改革,構建適宜的支付體系 5整合社保機構資源,加強新農合管理能力建設,完善監(jiān)督管理機制 6加快新農合法制化建設步伐 7統(tǒng)籌新農合與衛(wèi)生服務體系的協(xié)調發(fā)展,優(yōu)化新農合制度的外部環(huán)境
[Abstract]:Background of the study

With the rapid development of rural residents in China , the new rural cooperative medical system , which has been developed by the central government in 2002 , has led to more than 95 % of farmers returning to " who sees the disease and who pays for money " .

Study Objectives

Based on the view of sustainable development , through comprehensive analysis of the system of financing , compensation , supervision and external environment of the new farming system , this paper aims at promoting the transformation of the new farming system from " system establishment " to " quality improvement " , and promoting the sustainable development of the new farming system .

From the view of sustainable development , the author reviews the development course of cooperative medical system , discusses the causes of success and failure , summarizes its lessons and provides reference for the healthy and sustainable development of the new farming system .

2 From the view of sustainable development , the relevant theories are used to analyze the new farming system itself and its institutional environment , and explore the relevant factors to realize the sustainable development of the new farming system .

3 . Using the running data of the national new farming system , this paper describes the implementation status of the new farming system and analyzes the problems existing in the sustainable development of the new farming system .

Based on the case data of the new farming system in the three counties of the western part of China , the author analyzes the health situation and existing problems in the development process of the new farming system , and probes into the relevant factors that affect the sustainable operation of the new agricultural system .

5 Comprehensive theory and positive case analysis result , put forward the policy suggestion to realize the sustainable development of the new farming system .

Research Methods

1 Source

( 1 ) Literature data

Through the professional literature database such as China ' s known network and OVID and Google ' s academic search engine , the author uses " new rural cooperative medical scheme " , " cooperative medical scheme " , " cooperative medical treatment " , " traditional cooperative medical treatment " , and so on .

Collect new agricultural and forestry policy documents issued by the central government since 2002 to learn about the policy development and implementation of the new farming system .

( 2 ) Existing macroscopic data

Collect the 2006 - 2010 Chinese Statistical Yearbook , the China Health Statistics Yearbook and the 2006 - 2010 National Statistics Manual for New Agriculture in China .

( 3 ) Case information

The study collected from three counties ( cities ) of Zhongning County , Qingtongxia City and Yongding County of Ningxia Hui Autonomous Region as the research field , which included farmers , health service providers , new farm management and administrative decision makers .

2 Study Methods

( 1 ) System analysis method

The construction of the new farming system is a complex system engineering , which involves many subjects such as government departments , health institutions and rural residents at all levels , and the new farming system is a sub - system of the whole social security system , and the social security system is a sub - system of the whole society .

( 2 ) Historical analysis and comparative analysis

This paper reviews the development course of cooperative medical system , analyzes its own design and institutional environment from the perspective of sustainable development , discusses its successful and failed lessons , compares the development of old and old cooperative medical system , reveals the difference , and provides inspiration for the sustainable development of the current new farming system .

( 3 ) Theoretical analysis and empirical analysis

Based on the view of sustainable development , the paper makes a theoretical analysis on the design and operation mechanism of the new farming system based on the theory of institutional economics , welfare economics , health economics and social security , and provides scientific evidence to advance the sustainable development of the new farming system .

( 4 ) Existing data analysis and site investigation

Through consulting and carding professional literature related to cooperative medical treatment , this study is about the research results of cooperative medical system .
Through the collection of government policy documents on the development of the new farming system , we know the policies of the government to the development of the new agriculture ;
Through collecting the running data of the national new agriculture , the paper analyzes the implementation of the new farming and the existing problems .

In the case data of this study , on - site survey , including quantitative investigation of institutions and qualitative investigation of suppliers , demanders and management parties , were carried out in 3 project counties in Ningxia , and the development of new agriculture in 3 project counties was collected , and on - site data such as the views and suggestions of the supplier , the demander and the management side on the new agriculture were collected , which provided the basis for the depth analysis .

( 5 ) Qualitative research and quantitative research

In this study , qualitative and quantitative analysis is applied to the quantitative analysis of the data related to the operation of Xinong in three project counties of Ningxia , and the present situation and problems of the sustainable development of Xingnong in Ningxia Project County are analyzed by qualitative interviews with suppliers , demanders and management parties in three project counties .

Results of the study

Review and Analysis of the Development Course of Rural Cooperative Medical System

The old rural cooperative medical system is established on the basis of the collective economy , relying on the people ' s communes and relying on the low - cost medical service supply system , which meets the basic medical needs of the farmers at the time , and provides a low level of medical security .

But in essence , if all the problems encountered in social development are to be solved by all the resources of society , there may be no insurmountable problems , but in reality , this situation can only be short - term behavior and has no sustainability . In the end of the 1970s , the rural economic system reform , the social and economic environment of our country and the medical and health service system have undergone tremendous changes , and this equilibrium state is broken , so that the cooperative medical system is rapidly going to decline .

As can be seen , the institutional development , like economic development , is difficult to sustain if it is separated from the institutional environment , whether it goes beyond or behind the development of the environment , which is the core of the connotation of sustainable development and emphasizes the common coordinated development .

2 . Main results of theoretical analysis

The new agriculture association system is the primary social medical insurance system with Chinese characteristics , and the government should bear the leading responsibility in the construction and development of the new agricultural integration system , including organization guidance , system planning , financial support , management supervision and legislative responsibility ;


The design of the financing standard for the new farming system should take into consideration the per capita annual income of rural residents , the annual medical expenditure per capita and the government revenue . The responsibility of government financing at all levels should be clearer , especially the central government and provincial governments should bear more responsibilities ;


With the improvement of the financing level of the new agriculture , the compensation model of the new agriculture combined compensation can be changed to the welfare risk type . The compensation plan should take into account the characteristics of the local economy , the medical service system and the supplier of the medical service , the consumption characteristics of the farmers and other external environmental factors , and pay attention to the connection with other relevant systems .

Constructing a diversified mixed payment system is an effective measure to control the rapid increase of medical expenses and maintain the balance of the new agricultural fund .

As the competent department of the new agriculture association , the health department has restricted its implementation force to a certain extent , and has influence on the management effect , and can consider the gradual integration of the social security sector resources , which is beneficial to saving management resources .

Urbanization of rural areas , aging of population , change of disease spectrum , diversification of medical security needs and other problems bring challenges to the development of new agriculture and agriculture in the future , and the medical security system of urban and rural integration is urgent to be established .

3 Main results of the present situation of the running of Xingnong in the whole country

With the increase of farmers ' participation rate in 2011 to RMB 246 in 2011 , the number of beneficiaries of the new agricultural association increased from 38 yuan in 2006 to RMB 206 yuan in 2011 , and the number of beneficiaries per capita increased from 0.38 yuan in 2006 to RMB 206 yuan in 2011 .

The Main Results of New Rural Cooperative Case Study in Sanxian County , Ningxia

In 2006 - 2008 , the new agricultural co - financing standard of NingXia 3 project county ( city ) increased year by year , personal contribution increased from 10 yuan to 20 yuan per year , government subsidy at all levels increased from 40 yuan to 80 yuan , personal contribution accounted for less than 0.5 % of the annual average income of farmers , and the participation rate of farmers increased year by year . In 2009 , the participation rate of county ( city ) was more than 90 % . Under the precondition of increasing compensation ratio , farmers would like to raise the personal contribution amount .

In 2005 - 2007 , the compensation model combined with the outpatient family account and the hospitalization planning was implemented in the Xingnong District of Ningxia 3 Project County in 2005 . With the development of the new farming system and the change of the social environment , the outpatient compensation model was gradually changed in 3 project counties in Ningxia in 2008 , and the outpatient family account was gradually replaced by the outpatient department .

In 2005 - 2008 , NingXia 3 project county ( city ) carries out adjustment of hospitalization compensation plan every year , reduces hospitalization initiation line , cancels the cost section , increases the proportion of hospitalization compensation , and improves the capping line ;
The number and benefit rate of hospitalization compensation in three project counties ( cities ) increased year by year , but the economic burden of farmers ' disease was still heavy , especially the burden of large disease .

Overall , in 2006 - 2008 , the hospitalization of farmers in the county ( city ) of Ningxia in 2006 - 2008 tended to choose county hospitals , and the township hospitals lacked some appeal . In the same period , the hospitalization expenses of three project counties ( cities ) presented different trends . During the same period , the cost control of different medical institutions presented an upward trend , and the lack of scientific and effective supervision means for the cost control of medical institutions , and the inadequate supervision ability of the management department , made the supervision effect limited .

policy recommendations

1 . Strengthen the government ' s leading responsibility and clarify the content of government responsibilities at all levels

2 Establishment of a stable and long - term financing mechanism to gradually increase the level of integration and integration of the new agriculture

3 . Continue to vigorously promote outpatient co - ordination , formulate scientific and reasonable compensation scheme

4 . Accelerate the reform of payment system and construct appropriate payment system

5 . To consolidate the resources of social security institutions , strengthen the construction of new agricultural production management capacity , and improve the supervision and administration mechanism

6 Speed up the Construction of the Legal System of New Agriculture

7 . Coordinating the development of the new agriculture association and health service system and optimizing the external environment of the new farming system
【學位授予單位】：復旦大學
【學位級別】：博士
【學位授予年份】：2013
【分類號】：R197.1;F842.684;F323.89

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