中国新型农村合作医疗公平性与效率性研究
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摘要
新型农村合作医疗(简称新农合)是我国社会基本医疗保障制度的一个重要组成部分,与城镇职工基本医疗保险、城镇居民基本医疗保险共同构成我国社会基本医疗保险体系。
自2003年试点阶段至2009年末,我国新农合呈现良好的上升态势,其中参合率已经接近95%,距离“全覆盖”的新农合目标很近；人均筹资额由最初增加了1倍以上；补偿受益人次的年均增长率达到58.4%。在农民人口如此众多的泱泱大国,仅用5年的时间就能达到如此显著的成就,堪称受全世界瞩目的奇迹。然而,在成就面前,还必须清醒地看到,新农合还存在的诸多问题,主要表现在：筹资水平和补偿程度仍然很低,地区之间差异显著,农民“因病致贫、因病返贫”的风险依然非常严峻；门诊统筹覆盖面较低；基层医疗服务机构资源状况堪忧,农民依然面临“看病难”的问题：基层医疗服务机构“过度用药、过度诊疗”依然严重,农民依然面临“看病贵”的问题；新农合管理经办体系不健全,管理效率偏低。这些问题已经引起政府和众多学者的普遍关注。辽宁新农合发展状况是全国新农合发展状况的一个缩影,它的成就和存在的问题,既具有其个性,也必然具有共性。
作为我国社会医疗保障体系的一个重要组成部分,新农合所存在的问题综合体现为公平性和效率性的缺乏。在这样的背景下,本研究利用可获得的数据,运用计量分析方法,从全国东中西部、东部各省、辽宁各市三个层面,逐层次分析2003～2009年新农合的公平性和效率性,以图从新农合所存在问题的角度深入挖掘公平性和效率性缺乏的主要原因,从而为改善新农合公平性和效率性提供政策建议。
本文的基本研究思路是：首先,围绕新农合所存在的问题,广泛研读国内外已有的关于公平性和效率性及相关新农合研究的理论和实证研究资源；其次,吸收和领会关于公平性和效率性的经济学理论,作为本研究的理论基础。第三,选择适当的研究方法。第四,分层次研究全国东中西部、东部各省、辽宁各市新农合的公平性和效率性,由外而内地逐步明确全国之于东部、东部之于辽宁,辽宁内部的新农合状况。最后根据实证分析的结论提出改善新农合公平性和效率性的建议。
本文的研究结论与建议是：
1.即便是经济最为发达的东部,其内部各省之间的差异仍然非常显著,且这种差异对全国性整体差异构成重要影响。按照现行的区域划分方式来配置新农合资源、制定医疗制度改革方案(特别是基层医疗制度改革方案),在一定程度上缺乏针对性,必然影响资源配置和医疗制度改革的效果。因此,建议中央政府改变现有行政区域划分方式以针对性地制定新农合政策,根据医疗服务资源(尤其是基层医疗服务资源)的效率性来划分中国区域,以便有针对性地制定新农合政策。
2.经济发达程度是影响新农合基金筹资与补偿公平性的重要因素。在受经济发展水平所限、农民个人负担能力无法迅速提高的现状下,中央和地方政府应针对不同经济区域设计不同的新农合筹资与补偿制度,加大财政补助力度,尤其应该注重对经济落后地区的扶持。一方面努力实现经济发达区域的地方(市、县、乡)财政补助力度的逐步加大,另一方面将节省下来的中央和省级财政补助更多地向经济落后区域倾斜,以促进区域之间的公平性。
3.我国东部各省之间新农合筹资与补偿状况差异很大,是造成全国总体差异性的决定性因素。尽管我国东部是经济最为发达的区域,也是新农合发展态势最好的区域,但由于中央对东部的支持力度不同,加之各省地方财政对新农合的补助力度也不同,导致东部各省的新农合筹资与补偿状况存在很大差异。中央和地方政府应该密切注意东部区域各省新农合之间的协调发展,不断缩小东部各省之间的差异,从而有效提高全国新农合的公平性。
4.在“以收定支,略有结余”的运行原则下,新农合的有限筹资规模严重影响农民的补偿受益程度。提高筹资水平是促使新农合制度目标实现的必然路径。
5.在筹资规模有限且在短时期内不可能得到迅速改善的同时,医疗服务机构“过度用药、过度诊疗”导致农民医药费用膨胀,农民依然面临“因病致贫、因病返贫”的严重风险。各级政府必须注意实现住院补偿与门诊补偿之间的协调关系,在精算的基础上,形成科学合理的补偿方案,以有效提高补偿效用。
6.基层医疗服务资源质量是影响新农合目标实现的重要因素。农村地区的医疗资源不论从数量还是质量上都与城市相差悬殊,使得农民所能获得的基本医疗服务水平很低且没有明显的改善。各级政府应该在“新医改”政策的总体目标指引下,切实改善基层医疗服务资源的质量,使农村获得与城市相当的医疗服务,从而使农民真正通过新农合制度提高健康水平。鉴于我国农村基层医疗服务机构的现状,建立健全基层医疗卫生机构补偿机制的政策措施是重要的举措。
7.新的新农合政策推出会对各地新农合基金运行效率产生很大震荡。这种震荡尽管缘于国家新农合政策的剧变,但归根结底是缘于新农合资金管理和运行经验不足导致对政府的应变能力较差。在我国新农合已经基本实现“全覆盖”的今天,在新农合资金管理和运行经验仍然不足的现状下,新农合政策应该稳步推进,避免大幅度的政策调整。各级政府应该首先建立精确的精算和统计分析制度,并在此基础上适时、适度推出相关调整政策,确保新农合政策的阶段性顺畅对接,以实现新农合制度运行效率的稳定。
8.新农合基金运行技术水平的提升是影响新农合补偿深度和广度的重要因素。尽管我国各省的新农合基金运行效率在2007年以后呈现总体上升的态势,但个别省份(包括辽宁)仍然存在着因管理经验不足、管理水平较低、基金资源配置不当以及技术退步等诸多问题影响运行效率提升的状况。各级政府应大力提倡新农合制度优化与创新、管理方法和模式的创新,加强新农合基金运行的管理和经办能力。各级地方政府必须深刻领会中央政府新农合政策的重要意义与内涵,积极开展工作,逐步摸索出—条适合当地实际的新农合政策,大力倡导创新,以不断提高新农合制度设计、改革水平和新农合基金的管理水平。制度创新是重中之重,创新又来源于向先进省份学习、经验积累和前瞻性思维。
9.对于我国的新农合政策,应采取“公平优先,兼顾效率”的原则。新农合公平性的不是简单地体现在全覆盖下的“人人有医疗保障”,更需体现在农民可获得与城市居民相当的医疗服务与医疗保障、不同地区农民获得相当的医疗服务与医疗保障。还应从制度设计上处理好预防保健与疾病治疗的关系。“公平优先”不代表放弃效率性。新农合的效率性决定了农民所能获得的医疗费用补偿程度。目前,农民“看病难、看病贵”、“因病致贫、因病返贫”的风险依然非常严峻。在中央政府财力有限的前提下,地方政府应当根据自身财力状况不断加大对新农合的补助力度,使得当地农民所获得的医疗费用补偿得到逐年提高。
本文的创新点体现在以下5个方面：
1.将基尼系数和泰尔指数方法应用于新农合的公平性研究。根据泰尔指数的可分解性,本研究的侧重点在于泰尔指数方法的运用,而以基尼系数方法作为辅助验证。本研究的结果表明,所有指标的泰尔指数与基尼系数变化趋势基本相同,而分解后的泰尔指数更加清晰地揭示了公平性缺乏的主要影响来源。本文使用基尼系数和泰尔指数对辽宁乃至全国新农合主要指标的地区差异性进行分析比较,而以往的文献要么过多将其应用于社会资源分配的公平性研究,要么只局限于对新农合个别指标的研究。
2.将数据包络分析(DEA)方法应用于新农合基金的效率性研究。DEA方法的运用有效规避了基于参数的生产前沿面分析方法的局限性,同时能够明确揭示新农合基金运行效率性缺乏的原因。由于缺乏医疗服务状况数据,对新农合基金运行效率的研究侧重于基金筹资、补偿的综合作用效果的分析。在此基础上,将2003年和2008年全国卫生服务调查的统计数据分析用于补充性支持,以得出关于新农合的社会效率评价。
3.在对全国新农合公平性和效率性研究中,沿用了我国现行的经济区域划分方式(东部、中部和西部)；但在对辽宁新农合公平性和效率性研究中,根据各市农业生产人均生产总值对辽宁作出了经济区域划分,以各市揭示经济发展水平对其新农合实施效果的影响。使用辽宁人均农业产值来划分辽宁的经济区域,使得辽宁各经济区域新农合的比较研究更具有合理性。
4.利用权威数据对辽宁乃至全国新农合尽可能多的主要指标进行了较为全面、系统的分析与比较,从而得出较为完整的结论。而以往的文献只是针对单一的或较少的新农合指标进行分析。
5.提出按医疗服务资源(特别是基层医疗服务资源)状况划分中国区域的构想,为新农合的制度设计和政策支持等方面的改革提供方向。
由于新农合仅仅经过了7年的时间(其中包括试点阶段),加之数据的可获得性的限制,仅有各省2004～2098年的新农合统计数据、辽宁2004～2009年的新农合统计数据,而关于新农合实施以来医疗服务状况的数据则更为缺乏(卫生部仅在2003年和2008年开展中国卫生服务调查)。研究数据的相对不足和一定程度的缺失可能使得基于数据分析而得出的结论存在偏颇。与新农合相伴随的医疗服务资源状况在很大程度上影响了新农合制度的公平性和效率性。由于数据的缺乏,本文的研究只能更多的目光着眼于新农合基金数据的分析,而对医疗服务状况的分析涉猎不多。
The New Rural Cooperative Medical System (NRCMS) is an important part in the social medical insurance system of China, which, together with the Basic Medical Insurance for Urban Employees and the Basic Medical Insurance for Urban Residents, constitutes the basic medical insurance system of our society.
From 2003 to 2009, China's NRCMS showed good development tendency and the participants accounted for over 95 percent of the total rural population, nearly reached the target of "full coverage". The amount of funding for each person doubled and the average growth rate of the number of beneficiary reached 58.4%, which is regarded as a miracle in the great country with large population in the short 5 years. However, we should also realize clearly that there are many problems, such as the funding and compensation levels remain low, the difference among regions is remarkable, the risk of "returning to poverty due to illness" is still very serious, the overall coverage of clinic is low, the condition of primary medical services resources is poor and farmers are still facing "difficult to see a doctor", the phenomenon of "over-medication, over-treatment" is serious and farmers still face the trouble of " expensive to see a doctor", the current management system of NRCMS is low in efficiency and is not perfect. All the problems have attracted the attention of the government and many scholars.The NRCMS of Liaoning province is a microcosm of the whole country's, its achievements and problems are specific and universal.
As a important part of China's social medical security, the problems of NRCMS comprehensively reflect the lack of equity and efficiency. Under this background, by using the available data and quantitative analysis methods, NRCMS' equity and efficiency from 2003 to 2009 are analyzed respectively in the whole country, the east area and Liaoning province, in order to reveal the main reason of the lack of equity and efficiency from the angle of NRCMS' current problems, so that the policy advices about improving NRCMS' equity and efficiency are addressed.
The basic idea of this paper is:
First, according to the problem of the NRCMS, the author extensively read the articles on the equity and efficiency and other relating theoretical researches and empirical study at home and abroad; second, grasps economic theory about the equity and efficiency, and then take it as base of this paper. Third, chooses appropriate research methods; fourth, hierarchically researches the equity and efficiency of the NRCMS respectively in the whole country, the east area and Liaoning province. Finally, offer advice on improving the equity and efficiency of NRCMS.
The conclusion of this paper is:
1. Even in the most developed area, there is significant difference among princes and the difference affect the national difference. Allocating the resources of NRCMS and making the plan of medical system reform (especially the plan of basic medical system reform) based on the present partition way that lack pertinence would influence the effect of resource allocation and medical system reform. So in order to make proper policy, the central government should divide regions basing on the efficiency of medical service resources (especially basic medical service resources).
2. NRCMS funding and compensation equity are mostly contributed by economic development level. Based on the condition of restricted by the economic development level and farmer individual paying capacity cannot rapidly improving, the central and local governments should design different NRCMS funding and compensation system according to different economic area, increase financial aid efforts especially to the underdeveloped economic areas. On the one hand, the governments should work hard to increase financial subsidy in developed areas; on the other hand, the governments should put the saving central and local fund to underdeveloped areas to promote equity between regions.
3. The difference of NRCMS funding and compensation condition among the east provinces are significant, which is the decisive factor of national differences. Although the east area are the most developed in our country, as well as the best development of the NRCMS, the supporting levels by central and local governments are different, which result in the difference of NRCMS funding and compensation condition between the east area are significant. On the purpose of constantly anarrowing the differences between provinces in the east and promoting equity of the national NRCMS, the governments should pay more attention to the harmonious development of NRCMS among eastern provinces.
4. Under the principle of "expenditures according to revenues, slight surplus", limited financial scale seriously impact farmers'beneficial level. Promoting financing level is an inevitable path to reach the target of NRCMS.
5. When the funding scale is limited and that cannot be expanded in short time, excessive medicine use and excessive diagnosis and treatment of medical service institutes result in the farmers'excess medical expense and the farmers still face the risk of becoming or returning poor. In order to improve compensation utility effectively, governments at all levels should pay attention to achieve compatible relationship between in-patient services compensation and out-patient services compensation, and form scientific normative compensation programs basing on actuarial science.
6. The quality of basic medical services resources is one of the important factors which affect the realization of the NRCMS'purpose. The suburban's medical service resource is significant worer than urban's not only in quantity but also in qulity, resulting in the basic medical service level that the farmers received is significant low and has not yet be improved. Under the guideline of the overall objectives of the NRCMS, the governments at each level should effectively improve the quality of basic medical services resources, and make the farmers obtain the same medical care level as the urban citizen, finally help the farmers to benefit from the NRCMS. Because of the present state of medical service in rural area, it is an important act to establish and improve compensation mechanism of basic medical and health institutions.
7. Publishing the new NRCMS policy will have great impact on the operational efficiency of NRCMS fund all over the country. Although resulting from the sudden change of national NRCMS policies, the impaction results from the lack of the fund management and operational experience and the ability to meet an emergency is inadequate. Today, under the present situation that the fund management and operational experience is inadequate, the NRCMS policies should be advanced smoothly to avoid substantial policy adjustment. Governments at all levels should establish accurate actuarial and statistical system, adjust related policy on the base of the system timely and appropriately, ensure the smooth connecting of the phased NRCMS policies, so as to realize the stabilization of the operation efficiency of NRCMS.
8. It is important to enhance operational level in the NRCMS, which can impact the range and degree of NRCMS compensation. Although, overall, the operational efficiency of provinces in our country increased since 2007, some provices (include Liaoning) still has inadequate manegment experience, low management level, improper fund allocation and backward technology which effet operational efficiency improvement. Governments at all levels must advocate the NRCMS optimum and innovation, management method and pattern innovation so that the NRCMS fund operation ability is advanced. Governments at all levels must grasp the profound connotation and relevance of NRCMS policy made by the central government, take active action, explore suitable policy for the concrete conditions of local area, advocate innovation, increase the level of design and reform and the management of NRCMS fund. Among which system innovation is the most important and the first work. Innovation originates in learning from advanced area, the accumulation of experience and prospective thinking.
9. To the NRCMS, we should adopt the principle of "equity priority and giving attention to efficiency". The equity of the NRCMS not simply means that everybody all-covered having medical safeguard, but also the farmers obtaining proper medical service compared with urban citien's and also farmers in difference areas. We should also deal with the relations between the disease preventing and treating and encourage famers intensify disease preventing and diagnosing in early days under some corresponding restraint policy. Equity priority doesn't mean giving up efficiency. Farmers' compensated level depends on the efficiency of the NRCMS. Today, the farmers still face risks of treating difficultly and expensively and the risk of becoming or returning poor. Under the limitation of central government's financial input, local government, according to its realistic financial condition, should continuously enlarge the subsidy to farmers in order to enhance the local farmers' medical expense compensation year by year.
The innovation of this paper lies in the following five aspects:
1. In order to research the equity of the NRCMS, two methods, Gini coefficient and Theil index, were used. As the Theil index can be divided into several groups, the paper emphasis on making use of it. According to the research, the results of Gini coefficient and Theil index of all indicators change in the same direction, the divided Theil index also clearly reveals the main source that resulted in lacking of equity. In the paper, the above two methods were used to analyze regional differences of the main NRCMS indicators in Liaoning province and the whole country. However, previous studies mainly applied them either in equity study of social resources allocation or specific indicators of the NRCMS.
2. Apply the DEA method on study of NRCMS fund efficiency. The DEA method not only effectively avoids the limitations of the parameter method SFA but also clearly discover the reasons of low efficiency, so the method was used to evaluate the operating efficiency of the NRCMS fund. Because of lacking of medical statistics, the paper pays more attention on the general effect of funding and compensation, and before we arrive at the social efficiency evaluation of the NRCMS, we added some statistics of the Third and the Fourth National Health Service Survey.
3. When researching the equity and efficiency of the whole nation, the paper directly uses current administrative division (the east, middle and west area). But when researching the Liaoning province's, the paper divided the whole province into several areas basing on per-capita agricultural GDP, which demonstrated that different economic development would exert different effects on the NRCMS and also made the comparative research between areas more reasonable.
4. Compared with previous studies which analyzed single or a few indicators of the NRCMS, the paper uses authoritative data analyzing and comparing as more as possible indicators of Liaoning province and the whole county systematically, so the conclusions would be more integral.
5. The paper suggests that the authorities should divide areas on the base of medical resources, which indicates direction for the system designing and policy supporting of the NRCMS.
Because NRCMS has been implemented for only 7 years and the data is available with restrictions, the data is not enough, so the paper mainly collect the NRCMS data of each province from 2004 to 2008, Liaoning province, from 2004 to 2009, and data relating to medical service is even less. Though health resources largely affect the system's equity and efficiency, the paper analyze more on the NRCMS funds rather than medical service for lacking of related statistics.
自2003年试点阶段至2009年末,我国新农合呈现良好的上升态势,其中参合率已经接近95%,距离“全覆盖”的新农合目标很近；人均筹资额由最初增加了1倍以上；补偿受益人次的年均增长率达到58.4%。在农民人口如此众多的泱泱大国,仅用5年的时间就能达到如此显著的成就,堪称受全世界瞩目的奇迹。然而,在成就面前,还必须清醒地看到,新农合还存在的诸多问题,主要表现在：筹资水平和补偿程度仍然很低,地区之间差异显著,农民“因病致贫、因病返贫”的风险依然非常严峻；门诊统筹覆盖面较低；基层医疗服务机构资源状况堪忧,农民依然面临“看病难”的问题：基层医疗服务机构“过度用药、过度诊疗”依然严重,农民依然面临“看病贵”的问题；新农合管理经办体系不健全,管理效率偏低。这些问题已经引起政府和众多学者的普遍关注。辽宁新农合发展状况是全国新农合发展状况的一个缩影,它的成就和存在的问题,既具有其个性,也必然具有共性。
作为我国社会医疗保障体系的一个重要组成部分,新农合所存在的问题综合体现为公平性和效率性的缺乏。在这样的背景下,本研究利用可获得的数据,运用计量分析方法,从全国东中西部、东部各省、辽宁各市三个层面,逐层次分析2003～2009年新农合的公平性和效率性,以图从新农合所存在问题的角度深入挖掘公平性和效率性缺乏的主要原因,从而为改善新农合公平性和效率性提供政策建议。
本文的基本研究思路是：首先,围绕新农合所存在的问题,广泛研读国内外已有的关于公平性和效率性及相关新农合研究的理论和实证研究资源；其次,吸收和领会关于公平性和效率性的经济学理论,作为本研究的理论基础。第三,选择适当的研究方法。第四,分层次研究全国东中西部、东部各省、辽宁各市新农合的公平性和效率性,由外而内地逐步明确全国之于东部、东部之于辽宁,辽宁内部的新农合状况。最后根据实证分析的结论提出改善新农合公平性和效率性的建议。
本文的研究结论与建议是：
1.即便是经济最为发达的东部,其内部各省之间的差异仍然非常显著,且这种差异对全国性整体差异构成重要影响。按照现行的区域划分方式来配置新农合资源、制定医疗制度改革方案(特别是基层医疗制度改革方案),在一定程度上缺乏针对性,必然影响资源配置和医疗制度改革的效果。因此,建议中央政府改变现有行政区域划分方式以针对性地制定新农合政策,根据医疗服务资源(尤其是基层医疗服务资源)的效率性来划分中国区域,以便有针对性地制定新农合政策。
2.经济发达程度是影响新农合基金筹资与补偿公平性的重要因素。在受经济发展水平所限、农民个人负担能力无法迅速提高的现状下,中央和地方政府应针对不同经济区域设计不同的新农合筹资与补偿制度,加大财政补助力度,尤其应该注重对经济落后地区的扶持。一方面努力实现经济发达区域的地方(市、县、乡)财政补助力度的逐步加大,另一方面将节省下来的中央和省级财政补助更多地向经济落后区域倾斜,以促进区域之间的公平性。
3.我国东部各省之间新农合筹资与补偿状况差异很大,是造成全国总体差异性的决定性因素。尽管我国东部是经济最为发达的区域,也是新农合发展态势最好的区域,但由于中央对东部的支持力度不同,加之各省地方财政对新农合的补助力度也不同,导致东部各省的新农合筹资与补偿状况存在很大差异。中央和地方政府应该密切注意东部区域各省新农合之间的协调发展,不断缩小东部各省之间的差异,从而有效提高全国新农合的公平性。
4.在“以收定支,略有结余”的运行原则下,新农合的有限筹资规模严重影响农民的补偿受益程度。提高筹资水平是促使新农合制度目标实现的必然路径。
5.在筹资规模有限且在短时期内不可能得到迅速改善的同时,医疗服务机构“过度用药、过度诊疗”导致农民医药费用膨胀,农民依然面临“因病致贫、因病返贫”的严重风险。各级政府必须注意实现住院补偿与门诊补偿之间的协调关系,在精算的基础上,形成科学合理的补偿方案,以有效提高补偿效用。
6.基层医疗服务资源质量是影响新农合目标实现的重要因素。农村地区的医疗资源不论从数量还是质量上都与城市相差悬殊,使得农民所能获得的基本医疗服务水平很低且没有明显的改善。各级政府应该在“新医改”政策的总体目标指引下,切实改善基层医疗服务资源的质量,使农村获得与城市相当的医疗服务,从而使农民真正通过新农合制度提高健康水平。鉴于我国农村基层医疗服务机构的现状,建立健全基层医疗卫生机构补偿机制的政策措施是重要的举措。
7.新的新农合政策推出会对各地新农合基金运行效率产生很大震荡。这种震荡尽管缘于国家新农合政策的剧变,但归根结底是缘于新农合资金管理和运行经验不足导致对政府的应变能力较差。在我国新农合已经基本实现“全覆盖”的今天,在新农合资金管理和运行经验仍然不足的现状下,新农合政策应该稳步推进,避免大幅度的政策调整。各级政府应该首先建立精确的精算和统计分析制度,并在此基础上适时、适度推出相关调整政策,确保新农合政策的阶段性顺畅对接,以实现新农合制度运行效率的稳定。
8.新农合基金运行技术水平的提升是影响新农合补偿深度和广度的重要因素。尽管我国各省的新农合基金运行效率在2007年以后呈现总体上升的态势,但个别省份(包括辽宁)仍然存在着因管理经验不足、管理水平较低、基金资源配置不当以及技术退步等诸多问题影响运行效率提升的状况。各级政府应大力提倡新农合制度优化与创新、管理方法和模式的创新,加强新农合基金运行的管理和经办能力。各级地方政府必须深刻领会中央政府新农合政策的重要意义与内涵,积极开展工作,逐步摸索出—条适合当地实际的新农合政策,大力倡导创新,以不断提高新农合制度设计、改革水平和新农合基金的管理水平。制度创新是重中之重,创新又来源于向先进省份学习、经验积累和前瞻性思维。
9.对于我国的新农合政策,应采取“公平优先,兼顾效率”的原则。新农合公平性的不是简单地体现在全覆盖下的“人人有医疗保障”,更需体现在农民可获得与城市居民相当的医疗服务与医疗保障、不同地区农民获得相当的医疗服务与医疗保障。还应从制度设计上处理好预防保健与疾病治疗的关系。“公平优先”不代表放弃效率性。新农合的效率性决定了农民所能获得的医疗费用补偿程度。目前,农民“看病难、看病贵”、“因病致贫、因病返贫”的风险依然非常严峻。在中央政府财力有限的前提下,地方政府应当根据自身财力状况不断加大对新农合的补助力度,使得当地农民所获得的医疗费用补偿得到逐年提高。
本文的创新点体现在以下5个方面：
1.将基尼系数和泰尔指数方法应用于新农合的公平性研究。根据泰尔指数的可分解性,本研究的侧重点在于泰尔指数方法的运用,而以基尼系数方法作为辅助验证。本研究的结果表明,所有指标的泰尔指数与基尼系数变化趋势基本相同,而分解后的泰尔指数更加清晰地揭示了公平性缺乏的主要影响来源。本文使用基尼系数和泰尔指数对辽宁乃至全国新农合主要指标的地区差异性进行分析比较,而以往的文献要么过多将其应用于社会资源分配的公平性研究,要么只局限于对新农合个别指标的研究。
2.将数据包络分析(DEA)方法应用于新农合基金的效率性研究。DEA方法的运用有效规避了基于参数的生产前沿面分析方法的局限性,同时能够明确揭示新农合基金运行效率性缺乏的原因。由于缺乏医疗服务状况数据,对新农合基金运行效率的研究侧重于基金筹资、补偿的综合作用效果的分析。在此基础上,将2003年和2008年全国卫生服务调查的统计数据分析用于补充性支持,以得出关于新农合的社会效率评价。
3.在对全国新农合公平性和效率性研究中,沿用了我国现行的经济区域划分方式(东部、中部和西部)；但在对辽宁新农合公平性和效率性研究中,根据各市农业生产人均生产总值对辽宁作出了经济区域划分,以各市揭示经济发展水平对其新农合实施效果的影响。使用辽宁人均农业产值来划分辽宁的经济区域,使得辽宁各经济区域新农合的比较研究更具有合理性。
4.利用权威数据对辽宁乃至全国新农合尽可能多的主要指标进行了较为全面、系统的分析与比较,从而得出较为完整的结论。而以往的文献只是针对单一的或较少的新农合指标进行分析。
5.提出按医疗服务资源(特别是基层医疗服务资源)状况划分中国区域的构想,为新农合的制度设计和政策支持等方面的改革提供方向。
由于新农合仅仅经过了7年的时间(其中包括试点阶段),加之数据的可获得性的限制,仅有各省2004～2098年的新农合统计数据、辽宁2004～2009年的新农合统计数据,而关于新农合实施以来医疗服务状况的数据则更为缺乏(卫生部仅在2003年和2008年开展中国卫生服务调查)。研究数据的相对不足和一定程度的缺失可能使得基于数据分析而得出的结论存在偏颇。与新农合相伴随的医疗服务资源状况在很大程度上影响了新农合制度的公平性和效率性。由于数据的缺乏,本文的研究只能更多的目光着眼于新农合基金数据的分析,而对医疗服务状况的分析涉猎不多。
The New Rural Cooperative Medical System (NRCMS) is an important part in the social medical insurance system of China, which, together with the Basic Medical Insurance for Urban Employees and the Basic Medical Insurance for Urban Residents, constitutes the basic medical insurance system of our society.
From 2003 to 2009, China's NRCMS showed good development tendency and the participants accounted for over 95 percent of the total rural population, nearly reached the target of "full coverage". The amount of funding for each person doubled and the average growth rate of the number of beneficiary reached 58.4%, which is regarded as a miracle in the great country with large population in the short 5 years. However, we should also realize clearly that there are many problems, such as the funding and compensation levels remain low, the difference among regions is remarkable, the risk of "returning to poverty due to illness" is still very serious, the overall coverage of clinic is low, the condition of primary medical services resources is poor and farmers are still facing "difficult to see a doctor", the phenomenon of "over-medication, over-treatment" is serious and farmers still face the trouble of " expensive to see a doctor", the current management system of NRCMS is low in efficiency and is not perfect. All the problems have attracted the attention of the government and many scholars.The NRCMS of Liaoning province is a microcosm of the whole country's, its achievements and problems are specific and universal.
As a important part of China's social medical security, the problems of NRCMS comprehensively reflect the lack of equity and efficiency. Under this background, by using the available data and quantitative analysis methods, NRCMS' equity and efficiency from 2003 to 2009 are analyzed respectively in the whole country, the east area and Liaoning province, in order to reveal the main reason of the lack of equity and efficiency from the angle of NRCMS' current problems, so that the policy advices about improving NRCMS' equity and efficiency are addressed.
The basic idea of this paper is:
First, according to the problem of the NRCMS, the author extensively read the articles on the equity and efficiency and other relating theoretical researches and empirical study at home and abroad; second, grasps economic theory about the equity and efficiency, and then take it as base of this paper. Third, chooses appropriate research methods; fourth, hierarchically researches the equity and efficiency of the NRCMS respectively in the whole country, the east area and Liaoning province. Finally, offer advice on improving the equity and efficiency of NRCMS.
The conclusion of this paper is:
1. Even in the most developed area, there is significant difference among princes and the difference affect the national difference. Allocating the resources of NRCMS and making the plan of medical system reform (especially the plan of basic medical system reform) based on the present partition way that lack pertinence would influence the effect of resource allocation and medical system reform. So in order to make proper policy, the central government should divide regions basing on the efficiency of medical service resources (especially basic medical service resources).
2. NRCMS funding and compensation equity are mostly contributed by economic development level. Based on the condition of restricted by the economic development level and farmer individual paying capacity cannot rapidly improving, the central and local governments should design different NRCMS funding and compensation system according to different economic area, increase financial aid efforts especially to the underdeveloped economic areas. On the one hand, the governments should work hard to increase financial subsidy in developed areas; on the other hand, the governments should put the saving central and local fund to underdeveloped areas to promote equity between regions.
3. The difference of NRCMS funding and compensation condition among the east provinces are significant, which is the decisive factor of national differences. Although the east area are the most developed in our country, as well as the best development of the NRCMS, the supporting levels by central and local governments are different, which result in the difference of NRCMS funding and compensation condition between the east area are significant. On the purpose of constantly anarrowing the differences between provinces in the east and promoting equity of the national NRCMS, the governments should pay more attention to the harmonious development of NRCMS among eastern provinces.
4. Under the principle of "expenditures according to revenues, slight surplus", limited financial scale seriously impact farmers'beneficial level. Promoting financing level is an inevitable path to reach the target of NRCMS.
5. When the funding scale is limited and that cannot be expanded in short time, excessive medicine use and excessive diagnosis and treatment of medical service institutes result in the farmers'excess medical expense and the farmers still face the risk of becoming or returning poor. In order to improve compensation utility effectively, governments at all levels should pay attention to achieve compatible relationship between in-patient services compensation and out-patient services compensation, and form scientific normative compensation programs basing on actuarial science.
6. The quality of basic medical services resources is one of the important factors which affect the realization of the NRCMS'purpose. The suburban's medical service resource is significant worer than urban's not only in quantity but also in qulity, resulting in the basic medical service level that the farmers received is significant low and has not yet be improved. Under the guideline of the overall objectives of the NRCMS, the governments at each level should effectively improve the quality of basic medical services resources, and make the farmers obtain the same medical care level as the urban citizen, finally help the farmers to benefit from the NRCMS. Because of the present state of medical service in rural area, it is an important act to establish and improve compensation mechanism of basic medical and health institutions.
7. Publishing the new NRCMS policy will have great impact on the operational efficiency of NRCMS fund all over the country. Although resulting from the sudden change of national NRCMS policies, the impaction results from the lack of the fund management and operational experience and the ability to meet an emergency is inadequate. Today, under the present situation that the fund management and operational experience is inadequate, the NRCMS policies should be advanced smoothly to avoid substantial policy adjustment. Governments at all levels should establish accurate actuarial and statistical system, adjust related policy on the base of the system timely and appropriately, ensure the smooth connecting of the phased NRCMS policies, so as to realize the stabilization of the operation efficiency of NRCMS.
8. It is important to enhance operational level in the NRCMS, which can impact the range and degree of NRCMS compensation. Although, overall, the operational efficiency of provinces in our country increased since 2007, some provices (include Liaoning) still has inadequate manegment experience, low management level, improper fund allocation and backward technology which effet operational efficiency improvement. Governments at all levels must advocate the NRCMS optimum and innovation, management method and pattern innovation so that the NRCMS fund operation ability is advanced. Governments at all levels must grasp the profound connotation and relevance of NRCMS policy made by the central government, take active action, explore suitable policy for the concrete conditions of local area, advocate innovation, increase the level of design and reform and the management of NRCMS fund. Among which system innovation is the most important and the first work. Innovation originates in learning from advanced area, the accumulation of experience and prospective thinking.
9. To the NRCMS, we should adopt the principle of "equity priority and giving attention to efficiency". The equity of the NRCMS not simply means that everybody all-covered having medical safeguard, but also the farmers obtaining proper medical service compared with urban citien's and also farmers in difference areas. We should also deal with the relations between the disease preventing and treating and encourage famers intensify disease preventing and diagnosing in early days under some corresponding restraint policy. Equity priority doesn't mean giving up efficiency. Farmers' compensated level depends on the efficiency of the NRCMS. Today, the farmers still face risks of treating difficultly and expensively and the risk of becoming or returning poor. Under the limitation of central government's financial input, local government, according to its realistic financial condition, should continuously enlarge the subsidy to farmers in order to enhance the local farmers' medical expense compensation year by year.
The innovation of this paper lies in the following five aspects:
1. In order to research the equity of the NRCMS, two methods, Gini coefficient and Theil index, were used. As the Theil index can be divided into several groups, the paper emphasis on making use of it. According to the research, the results of Gini coefficient and Theil index of all indicators change in the same direction, the divided Theil index also clearly reveals the main source that resulted in lacking of equity. In the paper, the above two methods were used to analyze regional differences of the main NRCMS indicators in Liaoning province and the whole country. However, previous studies mainly applied them either in equity study of social resources allocation or specific indicators of the NRCMS.
2. Apply the DEA method on study of NRCMS fund efficiency. The DEA method not only effectively avoids the limitations of the parameter method SFA but also clearly discover the reasons of low efficiency, so the method was used to evaluate the operating efficiency of the NRCMS fund. Because of lacking of medical statistics, the paper pays more attention on the general effect of funding and compensation, and before we arrive at the social efficiency evaluation of the NRCMS, we added some statistics of the Third and the Fourth National Health Service Survey.
3. When researching the equity and efficiency of the whole nation, the paper directly uses current administrative division (the east, middle and west area). But when researching the Liaoning province's, the paper divided the whole province into several areas basing on per-capita agricultural GDP, which demonstrated that different economic development would exert different effects on the NRCMS and also made the comparative research between areas more reasonable.
4. Compared with previous studies which analyzed single or a few indicators of the NRCMS, the paper uses authoritative data analyzing and comparing as more as possible indicators of Liaoning province and the whole county systematically, so the conclusions would be more integral.
5. The paper suggests that the authorities should divide areas on the base of medical resources, which indicates direction for the system designing and policy supporting of the NRCMS.
Because NRCMS has been implemented for only 7 years and the data is available with restrictions, the data is not enough, so the paper mainly collect the NRCMS data of each province from 2004 to 2008, Liaoning province, from 2004 to 2009, and data relating to medical service is even less. Though health resources largely affect the system's equity and efficiency, the paper analyze more on the NRCMS funds rather than medical service for lacking of related statistics.
引文
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