医疗保障补偿政策对乡-城流动人口住院服务利用行为影响的系统研究

China's medical insurance system is managed by local governments. The internal migrants’ medical insurance belongs to areas different from their residential areas, which would affect the migrants’ utilization of inpatient health services. In order to solve the problem of hospitalization compensation for four groups of populations including migrants, the medical insurance direct settlement policy for medical insurance was implemented in an all-round way in 2018. Studies have indicated that this policy directly affected the in-situ hospitalization behaviour of the internal migrants (whether use the inpatient service, hospitalization location and choice on medical institutions after filling in illness). Besides, hospitalization utilization behaviour is also affected by factors from individuals. Policies would also affect individual factors. However, the specific path of indirect impact and the degree of effect of the medical insurance policy on hospitalization utilization behaviour were still unclear. Therefore, this study takes the rural-to-urban migrants who are in need of inpatient service as the research object, uses the China Migrants Dynamic Survey and the field survey data, and uses the structural equation model to systematically analyze the direct and indirect impact through other factors of the medical insurance's compensation policy on the inpatient service utilization behaviour among the migrants. Then, we would build the systematic model of the influence of medical insurance on inpatient service utilization of the migrants. Based on this model, we would use the simulation analysis to predict the total impact of different compensation policies on the inpatient service behaviour among migrants after the implement of medical insurance direct settlement policy for medical insurance. Results of this research can be used to predict the policy effect of medical insurance direct settlement policy for medical insurance, and provide a basis for the choice of the compensation policy of this direct settlement policy.

中国医疗保障实施属地化管理。流动人口医保参保地和居住地不一致，在居住地就医报销困难，影响该人群住院服务利用行为。为解决含流动人口在内的四类人群异地住院报销问题，2018年医保异地就医直接结算政策全面落地。研究发现该政策直接影响流动人口住院行为（患病后是否住院、住院地点和医疗机构选择）。同时，住院行为还受个人因素影响，医保政策也会影响个人因素。但医保政策是否通过个人因素对住院行为产生间接影响及具体路径和作用程度尚不清楚。因此，本研究以需住院的乡-城流动人口为研究对象，利用流动人口动态监测和现场调查数据，采用结构方程模型，系统分析补偿政策对流动人口住院行为的直接影响和通过其他因素产生的间接影响，建立补偿政策对流动人口住院行为影响的系统模型；并利用该模型模拟分析，预测异地就医直接结算后，不同补偿政策对流动人口住院行为的影响。研究结果可用于预测异地就医直接结算的政策效果，为补偿政策的选择提供依据。

中国医疗保障实施属地化管理。流动人口医保参保地和流入地不一致，在流入地就医报销困难，影响该人群住院服务利用行为。2018年医保异地就医直接结算政策全面落地，旨在解决异地住院报销问题，是流动人口住院行为的关键影响因素。本研究以需住院的乡-城流动人口为研究对象，利用2014年流动人口动态监测和2015年中国城市统计年鉴数据，在文献和理论研究的基础上，采用结构方程模型，系统分析补偿政策对流动人口住院服务利用和行为的直接影响、间接影响，建立补偿政策对流动人口住院服务利用和行为影响的系统模型；并利用该模型模拟分析，预测异地就医直接结算对流动人口住院行为的影响。研究结果发现，影响流动人口住院服务利用行为的因素可以分为三大类，即政策环境因素、医疗机构因素及个人因素，不同类别中的部分因素之间及同一类别中的因素间存在相互影响；医保政策与流动人口住院服务利用的结构方程模型选择是否参加城镇医保作为医保政策代理变量，发现参保情况与住院服务利用间仅存在一条直接影响路径，路径系数为-0.127（p=0.004），说明未参加城镇医保的乡-城流动人口更不易利用住院服务；医保政策与流动人口住院行为结构方程模型选择城镇医保参保情况作为医保政策代理变量，发现参加城镇医保的乡城流动人口更不易选择返乡住院（路径总效应-0.627，p<0.001），并倾向于利用高层级医疗机构的住院服务（路径总效应0.251，p<0.001），代理变量报销方式和实际补偿比例由于与因变量之间存在较强的双向因果关系，结果与理论不符；不同住院行为间仅住院地点对住院医疗机构选择的影响显著，路径系数为-0.374。模拟分析结果发现，医保异地就医直接结算政策实施后，流动人口住院率上升至85.84%，返乡概率下降至8.1%，选择乡镇级、区县级、市级及以上医疗机构人数分别占7.48%、39.04%和53.48%。研究结果对预测异地就医直接结算的政策效果提供依据。