基于UHC视角的大病医疗保险补偿模式动态优化及基金支出规模研究

This study applies a natural intervention—Catastrophic Health Insurance and effectively combine with previous projects，which will save the cost of baseline study and improve study efficiency. Based on the UHC framework of WHO, this study will evaluate different reimbursement modes of Catastrophic Health Insurance in rural areas of Midwest China, analysis the joint effects of Catastrophic Health Insurance with New Rural Cooperative Medical Scheme and Medical Financial Assistance and position the function of Catastrophic Health Insurance from the Perspective of UHC. Then, based on the distribution characteristics of patients’ health expenditure, we will build a loss distribution function of Catastrophic Health Insurance by limited Pareto distribution method and the Kernel density estimate. Besides, we will analyze the panel data before and after the implementation of Catastrophic Health Insurance by PSM-DID method and the Probit model in order to forecast the service utilization of catastrophic patients under different reimbursement pattern parameters and further to build the correlation among reimbursement parameters, the UHC security effect and the scale of fund expenditure. Finally, by the method of incremental cost-effective analysis, this study will evaluate reimbursement efficiency of different reimbursement models and build a method to dynamically optimize Catastrophic Health Insurance reimbursement modes and the scale of fund expenditure dynamically. This study will not only expand the breadth and depth of these methods, but also provide theoretical and practical basis for scientifically selecting proper reimbursement modes of Catastrophic Health Insurance, therefore perfecting urban and rural medical security in China.

本研究利用大病医疗保险这一自然干预手段，与前期项目有效衔接，节省了基线调查成本，提高了效率。以WHO的UHC框架评估中西部农村大病医疗保险补偿模式，分析其与新农合、医疗救助的联合保障效应，并从UHC视角对其功能进行定位。然后结合大病患者医疗费用分布特点，综合运用限制性帕累托分布法、非参数核密度估计法等多种精算模型建立大病医疗保险损失分布函数；对大病医保前后的面板数据综合运用PSM-DID方法和Probit模型预测不同补偿模式参数下大病患者的服务利用，进一步构建“补偿参数—UHC保障效应—基金支出规模”之间的联动关系模型。最后运用增量成本效果分析评估不同补偿模式的补偿效率，确定动态优化大病医疗保险补偿模式和基金支出规模的方法。本研究不仅拓展了这些方法在卫生领域运用的广度和深度，而且为有限筹资水平下科学选择适宜的大病医疗保险补偿模式提供了理论和实践依据，以促进我国城乡医疗保障制度的不断完善。

本研究以WHO的UHC框架评估中西部农村大病医疗保险补偿模式，分析其与新农合、医疗救助的联合保障效应。B地仅有2.58%的住院人群获得大病保险补偿，A地因经济原因提前出院的占比16.69%。两地大病患者自付费用均超过2万元，因病致贫患者占比均超过60%，因病借债率也分别高达65.90%和72.86%。间断时间序列结果显示大病保险挤占了基本医保资金，导致基本医保补偿水平有所下降，同时大病医保人口覆盖和费用覆盖相对有限，导致大病保险并未有效降低患者经济负担。在预测补偿方案参数调整所引起的卫生服务需求释放基础上建立补偿方案参数变化、保障效应和基金支出规模的联动模型，随着大病保险和救助报销比例增加，患者因病致贫解决程度同步增加，但不超过30%。将家庭收入和自付费用比例作为纳入标准的救助方案集中指数为负数，贫困人群受益更多。通过倾向得分匹配计算出适用于大病人群保险因子的公式为N_r=1+2.685*(R_i-R_0) 。成本效果分析结果显示大病患者费用过高，导致报销比例过低时，减少大病患者因病致贫的成本效果较差。通过精算模型测算发现随着补偿方案调整，部分大病保险方案基金支出超出筹资水平。.现行大病保障UHC保障效应有限，应以减缓因病致贫为最终目标优化。大病保险应坚持以收定支实现风险共担，考虑当地筹资水平，采用“成本-效果”评价，关注参数变化-UHC保障效应-基金支出规模的联动。应关注人口覆盖，适度调整起付线，尽量提高报销比例，改善费用覆盖效果，才能有效缓解因病致贫。大病保险因子大于传统保险因子，测算基金支出需同步考虑参数变化带来的卫生服务需求变化。大病医疗救助对象确定应将居民收入与自付费用比值作为纳入标准，提高救助比例，财政筹资，对因病致贫患者切实发挥兜底作用，保证制度公平。加强大病保险和大病医疗救助衔接，同时应积极发挥生活救助作用，协同大病保障体系共同减少因病致贫。