非理性就医对医保费用管理的挑战及应对策略

目的分析参保患者非理性就医现象,积极探索应对策略,为控制不合理增长的医疗费用提供参考。方法结合我院医保工作中对医保基金正确合理使用的管理及参保患者的就医情况,分析近年来参保患者非理性就医的现象、原因及结果,探索应对策略,总结规范化管理的措施。结果小病大治、大病贵治、无病保养等是非理性就医的主要表现,严重影响医保费用的管理,助推了过度医疗和医疗费用的不合理增长。结论应落实国家医药卫生体制改革,完善配套的医疗保险政策,深化医院医保费用管理,科学控制基本医疗付费总额,控制医疗费用不合理增长,从而保障医保基金的安全使用。     

Health insurance and consumption: Evidence from China’s New Cooperative Medical Scheme

We exploit a quasi-natural experiment arising from the introduction of a health insurance program in rural China to examine how the insurance coverage affects household consumption. Results show that, on average, the health insurance coverage increases nonmedical-related consumption by more than 5%. This insurance effect is observed even in households with no out-of-pocket medical spending. In addition, the insurance effect is stronger in households with worse self-reported health status. These results are consistent with the precautionary savings argument. The insurance effect also varies by household experience with the program. In particular, the effect is significant only in villages where some households have actually obtained reimbursement from the insurance program. The program within these villages stimulates less consumption among new participants than among households that have participated in the program for more than a year.     

我国新型农村合作医疗发展现状及对策

本文利用《中国卫生统计年鉴》中的新型农村合作医疗情况数据,对我国新农村合作医疗发展状况进行研究,结果表明,我国新农合基本实现全覆盖,但新农合筹资水平与保障水平偏低.受地区经济发展水平、政府补贴不同的影响,各地区之间新农合发展存在差异.并提出根据各地区的经济水平,实施动态筹资水平,进一步完善医疗保险统计制度方法,增加数据透明度等手段来促进新农合发展.     

PPP模式在城乡居民医保一体化建设中的应用——以湛江为例

在基本公共服务均等化的大背景下,湛江市引入PPP模式,在城乡居民医保一体化建设中取得了显著成效。通过对湛江经验的分析,文章认为,确立政府的主导地位,在此基础上积极发挥市场的作用,构建多元主体的公私合作伙伴关系,实现经济效益和社会效益的统一,是适应市场经济发展要求,构建城乡一体化医疗保障制度的必然选择。     

Economic outcomes of exenatide vs liraglutide in type 2 diabetes patients in the United States: results from a retrospective claims database analysis

Abstract

Objective:

The safety and efficacy of the GLP-1 receptor agonists exenatide BID (exenatide) and liraglutide for treating type 2 diabetes mellitus (T2DM) have been established in clinical trials. Effective treatments may lower overall treatment costs. This study examined cost offsets and medication adherence for exenatide vs liraglutide in a large, managed care population in the US.

Methods:

This was a retrospective cohort analysis comprising adult patients with T2DM who initiated exenatide or liraglutide between 1/1/2010 and 6/30/2010 and had 6 months pre-index and post-index continuous eligibility. Patients were propensity score-matched to controls for baseline differences. Medication adherence was measured by proportion of days covered (PDC). Paired t-test and McNemar’s test were used to compare outcomes.

Results:

Matched exenatide and liraglutide cohorts (n?=?1347 pairs) had similar average total 6-month follow-up costs ($6688 vs $7346). However, exenatide patients had significantly lower mean pharmacy costs ($2925 vs $3272, p?<?0.001). Among liraglutide patients, patients receiving the 1.8?mg dose had significantly higher average total costs compared to those receiving the 1.2?mg dose ($8031 vs $6536, p?=?0.026), with higher mean pharmacy costs in the 1.8?mg cohort ($3935 vs $3146, p?<?0.001). There were no significant differences in inpatient or outpatient costs or medication adherence between groups (mean PDC: exenatide 56% vs liraglutide 57%, p?=?0.088).

Limitations:

The study assumed that all information needed for case classification and matching of cohorts was present and not differential across cohorts. The study did not control for covariates that were unavailable, such as HbA1c and duration of diabetes.

Conclusions:

Patients initiating exenatide vs liraglutide for T2DM had similar medication adherence and total healthcare costs; however, exenatide patients had significantly lower total pharmacy costs. Patients prescribed 1.8?mg liraglutide had significantly higher costs compared to those on 1.2?mg.     

Healthcare costs associated with nephrology care in pre-dialysis chronic kidney disease patients

Abstract

Objective:

To compare the healthcare costs of pre-dialysis chronic kidney disease (CKD) patients cared for in a nephrology clinic setting versus other care settings.

Methods:

An analysis of health claims between 01/2002 and 09/2007 from the Ingenix Impact Database was conducted. Inclusion criteria were ≥18 years of age, ≥1 ICD-9 claim for CKD, and ≥1 estimated glomerular filtration rate (eGFR) value of <60?mL/min/1.73?m². Patients were classified in the nephrology care cohort if they were treated in a nephrology clinic setting at least once during the study period. Univariate and multivariate analyses were conducted to compare average annualized healthcare costs of patients in nephrology care versus other care settings.

Results:

Among the 20,135 patients identified for analysis, 1,547 patients were cared for in a nephrology clinic setting. Nephrology care was associated with lower healthcare costs with an unadjusted cost savings of $3,049 ($11,303 vs. $14,352, p?=?0.0014) and a cost ratio of 0.8:1 relative to other care settings. After adjusting for covariates, nephrology care remained associated with lower costs (adjusted cost savings: $2,742, p?=?0.006).

Limitations:

Key limitations included potential inaccuracies of claims data, the lack of control for patients’ ethnicity in the calculation of eGFR values, and the presence of potential biases due to the observational design of the study.

Conclusions:

The current study demonstrated that pre-dialysis CKD patients treated in nephrology clinics were associated with significantly lower healthcare costs compared with patients treated in other healthcare settings.     

Prevalence and cost of hospital medical errors in the general and elderly United States populations

Abstract

Objective:

The primary objective of this study was to quantify the differences in the prevalence rate and costs of hospital medical errors between the general population and an elderly population aged ≥65 years.

Methods:

Methods from an actuarial study of medical errors were modified to identify medical errors in the Premier Hospital Database using data from 2009. Visits with more than four medical errors were removed from the population to avoid over-estimation of cost. Prevalence rates were calculated based on the total number of inpatient visits.

Results:

There were 3,466,596 total inpatient visits in 2009. Of these, 1,230,836 (36%) occurred in people aged ≥ 65. The prevalence rate was 49 medical errors per 1000 inpatient visits in the general cohort and 79 medical errors per 1000 inpatient visits for the elderly cohort. The top 10 medical errors accounted for more than 80% of the total in the general cohort and the 65+ cohort. The most costly medical error for the general population was postoperative infection ($569,287,000). Pressure ulcers were most costly ($347,166,257) in the elderly population.

Limitations:

This study was conducted with a hospital administrative database, and assumptions were necessary to identify medical errors in the database. Further, there was no method to identify errors of omission or misdiagnoses within the database.

Conclusions:

This study indicates that prevalence of hospital medical errors for the elderly is greater than the general population and the associated cost of medical errors in the elderly population is quite substantial. Hospitals which further focus their attention on medical errors in the elderly population may see a significant reduction in costs due to medical errors as a disproportionate percentage of medical errors occur in this age group.     

我国县乡医疗市场垄断均衡与破除对策研究

中国县乡医疗体制改革改变了原有计划经济体制下医疗卫生服务供给低效率和数量短缺的局面。但是,中国县乡医疗市场正在出现新的、医政联合的垄断格局。中国县乡垄断医疗市场短期与长期均衡形成及持续是各方力量博弈的结果,垄断医疗机构从中获得巨额垄断利润,而农民却支付巨额成本。文章在模型分析结论基础上,提出了建立准入性竞争医疗体系、提升农民的组织和谈判能力、变革政府职能和完善公共卫生政策三大破除县乡医疗市场垄断均衡的对策性思考。     

保定市大学生医疗保险制度运行探析

为帮助大学生顺利完成学业,保障大学生享有基本医疗卫生服务权益,国务院于2008年年底决定将大学生纳入城镇居民基本医疗保险试点范围。制度运行两年多来取得了可喜的成绩,也暴露出许多问题。通过对保定市六所高校在校生进行问卷调查,发现问题集中表现为:大学生对制度了解较少,参保率低,学校医疗机构服务质量差、效率低,制度保障范围狭窄,转移接续难等。本文将根据分析结果,阐述问题根结所在,并试提出解决方案。目的是使大学生医疗保险制度真正能提高大学生的医疗福利水平,减轻大学生的医疗费用的负担。     

医疗护理服务可及性对居家老人照料服务选择的影响研究——基于北京市的实证研究

利用课题组2018年在北京市的抽样调查数据,运用Logistic回归方法考察医疗护理服务可及性对居家老人照料服务选择的影响。结果发现,医疗护理服务的便捷性、可支付性与老人照料服务的选择显著相关。住所附近有医疗卫生机构、有提供上门护理服务的机构或是与家庭医生签约的老人,更倾向于选择社会照料服务;支付能力对照料服务的选择呈现"U"型效应:家庭支付能力较强或者经济自评相对不足的老人更倾向于选择社会照料服务。应通过优化医疗护理资源布局、建立并完善社会照料服务的价格机制等措施,推进高效、可持续的社会照料服务体系的构建。