医疗保险是否改善了老年人的慢性病医疗状况? ——基于CHARLS数据的实证分析

本文基于中国健康与养老追踪调查(CHARLS)数据,利用Heckman样本选择模型、二阶段最小二乘模型(2SLS)等方法,在高血压、糖尿病等慢性病纳入医保门诊报销的背景下,实证检验了医疗保险对我国城乡老年人慢性病医疗状况的影响.研究发现:(1)医疗保险显著增加了老年人慢性病的门诊和住院医疗费用,且城市和男性老年人的支出明显高于农村和女性老年人,但医疗保险对老年人慢性病住院医疗支出增长的影响呈减弱趋势;(2)医疗保险显著提高了老年人慢性病医疗服务利用率,增加了老年人及时就医的概率;(3)医疗保险显著降低了老年人慢性病的自付比例,减轻了老年人的医疗负担.     

The Effect of Reimbursement on the Intensity of Hospital Services

We examine how hospital treatment intensity is affected by an exogenous change in average reimbursement for an admission. Theory predicts that treatment intensity would be most affected for highly profitable services but unaffected for unprofitable services. We use Medicare inpatient data from 11 states for 16 disease categories that vary in the generosity of reimbursement to test this prediction. Using the coefficients from quantile regressions, we calculate a difference-in-difference estimate of the effect of the Balanced Budget Act (BBA) of 1998, comparing the pre- and post-BBA change in treatment intensity at high Medicare share hospitals to low Medicare share hospitals. We find that not-for-profit hospitals cut treatment intensity at the 50th, 75th, and 95th quantiles only for generously reimbursed services. Intensity at the 25th percentile was unaffected, regardless of generosity. We did not measure a statistically significant response at for-profit or public hospitals to the BBA.     

我国分级诊疗模式是否能节约医疗资源

本研究借鉴2014版的Andersen模型构建分级诊疗与医疗资源利用的理论框架,并基于2008-2014年126个城市的平衡面板数据,利用双重差分法量化评估我国行政主导下的非强制性分级诊疗模式的实施效果,作者首次检验了医疗生产要素规模、人口老龄化程度在分级诊疗对医疗资源利用影响中的调节作用。该研究发现：（1）分级诊疗的实施显著节约了门急诊与住院服务资源利用,并且平行趋势检验、安慰剂检验、PSM-DID等方法的结果仍然稳健。（2）通过异质性分析发现,地区医疗生产要素规模越大,分级诊疗对门急诊服务资源的节约效应越强。（3）地区人口老龄化水平越高,分级诊疗对住院服务资源的节约效应越强。基于上述结果,作者认为在人口老龄化背景下,实施分级诊疗可以优化医疗资源配置,提升医疗服务利用效率,减少医疗资源浪费,但是,我国深化分级诊疗改革,必须平衡不同层级医疗机构之间的利益关系,实现不同层级医疗机构从利益竞争到分工合作。该研究科学论证了我国分级诊疗模式能有效节约门急诊与住院服务资源利用,为人口老龄化背景下完善分级诊疗模式提供理论指导,也为进一步深化医疗体制改革提供借鉴参考。     

Resource allocation, equality of access and health

Based upon the experience of Tanzania, this paper relates resource allocation in the health sector to the output of health, by contrasting access to and utilization of available health services by urban and rural populations. The writer argues that increased health expenditures alone cannot yield an efficient health care return unless the additional expenditure is spread ‘thinly’, in keeping with the realities of population distribution, transport possibilities, and disease patterns in most poor countries. Detailed data are presented for recurrent and capital expenditures for health facilities at different levels, and the output of those institutions is considered in terms of the volume of services offered. Those services are then measured according to their utilization by urban and rural populations. Because referral systems are found to function only marginally, it is argued that further building of large hospitals is not justified in the present situation of most poor countries. Specifically, the writer describes the ways in which Tanzania is changing its inefficient and unjust health care system. The paper concludes that the major obstacles to change are not shortages of resources or technologic ignorance but social systems that do not place high value upon the health care needs of rural peasants. It is in this way that the professional and elitist interests of the few are often destructive of the needs of the many.     

Intergenerational Inequality and the Contract Out Policy in Public Health Care

This study investigates the impact of a Japanese public health care reform—called the contract out policy—on intergenerational inequality and the probability of a surplus in medical saving accounts. First, I investigate the change in the lifetime net burdens for each generation and public health expenditures and conduct simulation analyses to consider the effects of contracting out public health insurance on intergenerational inequality using the generational accounting method. Next, I simulate the probability of a surplus in medical savings accounts using the transition probability of health care expenses based on individual health data, such as receipt data. According to the simulation results, the net lifetime burden on future generations after contracting out shows a 1% reduction compared to the base case, which is not implemented in public health care reform. In addition, the probability of medical savings accounts remaining in surplus, including cases of zero medical expenses, is 69.6%.     

Health care cost of floods: Evidence from Typhoon Morakot in Taiwan

Using the difference-in-difference (DID) method, this study uses Typhoon Morakot, which occurred in August 2009, as an example to estimate the effect of flooding on health care cost burden. The main data source is the medical claims records of a cohort of three million patients in Taiwan’s National Health Insurance system. By examining flood-related physiological diseases and disaster-related mental illnesses, our results indicate that the increase in outpatient health care costs resulting from the flood caused by the typhoon is approximately NTD 8.95 billion (USD 280 million), equivalent to approximately 69% of the annual special budget for flooding prevention during the period 2006–2019 in Taiwan. Moreover, the increase in outpatient expenditure for mental illnesses is nearly 10 times that of physiological diseases. An important implication of our findings is that the cost of preventing natural disasters, such as floods, can be offset by saving health care costs, particularly for mental illnesses. Our results also suggest that in addition to providing safe drinking water and indoor residual spraying, offering continuous post-disaster mental health services can further save health care expenditures caused by natural disasters.     

Substitutional effect of long-term care to hospital inpatient care?

In China, many of the top- and second-tier hospitals are overcrowded, this is partly due to the fact they are providing services which can provided by other medical facilities such as long-term care. The implementation of the Qingdao Long-term Care Medical Insurance (LTCMI) which began as a pilot in Qingdao in 2012 may alleviate the burden of overcrowding in these hospitals. In this pilot, the Qingdao government shifted patients who did not require hospital inpatient care from top- and second-tier hospitals to lower tier facilities, care homes and home care to i) reduce the expenditure of patients, ii) reduce the burden on the top- and second-tier hospitals and iii) improve delivery (from a time and geographic perspective) of long term care to those that need such attention.The purpose of this paper is to assess the impact of this policy from a burden and cost perspective. Our finding suggests that there is a reduction in costs to all stakeholders. The total cost to the government-subsidized medical insurance decreases by around $7918 RMB per recipient. The cost to the individual decreases by around $2324 RMB per recipient. Thus, netting a decrease of $10,242 RMB in total expenditure. Furthermore, we find that there is a 12% reduction in inpatient service after a recipient participates in the pilot. Given the reduction in costs and admissions, this does indicate some level of success with the program. This paper concludes by examining the policy implications of these results.     

补充医疗保险对中老年人医疗服务利用的影响研究

我国基本医疗保障制度顶层设计逐渐完善，但针对部分高额医疗费用，基本医保的报销水平仍然有限，与基本医疗保险相衔、面向全体基本医疗保险参保人员的补充医疗保险将作为在更大范围分散风险的补偿手段满足人民群众的医疗需求，为此探究补充医疗保险对中老年人医疗服务利用的影响。 采用2018年中国健康与养老追踪调查（CHARLS）的数据，构建两部模型进行分析探究。 结果表明，补充医疗保险增加了中老年人体检、门诊和住院的可能性，同时减少了其在门诊费用支出。 因此，政府应鼓励居民购买补充医疗保险，以解决基本医疗保险无法满足患者的医疗服务需求的问题，同时为我国补充医疗保险发展提出相关建议。     

Does health insurance promote people's consumption? New evidence from China

In order to change the situation that reimbursement rate of the new rural cooperative medical care system (NCMS) was too low to alleviate farmers medical burden, in August 2012, China began to expand the coverage of the NCMS to include the treatment of critical illnesses. Could more effective health insurance promote the consumption of rural residents? We studied the impact of the critical illness insurance (CII) on rural household consumption, and find that the CII increases per capita household daily consumption by >15%. But healthcare and medical expenditures have not been affected. Our comparison of outcomes for households with different levels of consumption and income shows the CII mainly promote the consumption of rural affluent family, but no incentive for poor family, resulting in deterioration of consumption inequality of rural households. The finding is robust to various alternative hypotheses and specifications.     

公立医院 “成本病” 与医疗负担——兼论 “药品零加成” 政策的影响

公立医院是我国医疗卫生体系的主体,是新医改成功的关键,但多年来缺乏完善的成本核算体系,也加重了患者和政府的医疗负担。文章利用2013-2018年中部某省658家公立医院数据,基于Baumol"成本病"理论,构造新的"调整的鲍莫尔变量",首次从微观视角检验公立医院"成本病"的存在性,并考察了"成本病"是否加重了患者和政府负担;进一步结合"药品零加成"政策的实施,探究了其对公立医院"成本病"效应的影响。研究发现,我国公立医院系统同样存在"成本病"现象,且是加重患者与政府医疗负担的重要原因;"成本病"对患者医疗负担的影响并无医院等级差异,对政府医疗支出的影响在二级医院更为明显。结合样本期内"药品零加成"政策的实施发现,政策有效降低了患者负担,但加重了政府医疗支出,也未能缓解公立医院的"成本病"问题,但有助于医技成本支出的降低。研究具有重要的政策启示:"成本病"已经成为制约公立医院可持续发展的重要影响因素,亟需建立有效的成本核算管理工具和机制,健全公立医院薪酬制度,促进公立医院管理向精细化、规范化转型,抑制"成本病"问题,保障公立医院健康、可持续发展。     

Health system reform in China: What role for private insurance?

The purpose of the present paper is to show that much of the literature on health economics and on the international experience with different forms of health system organization can be interpreted as supporting the idea that reliance on an unregulated market mechanism for organizing the production and financing of health services is likely to result in major problems both with respect to efficiency and equity. However, reliance on a centralized “command-and-control” model managed by government has also been shown to entail problems in practice. For this reason I argue that the best option at China's current state of development may be a compromise model in which competing private providers are given an important role, both for the production of health services and in the provision of health insurance, but in which the government intervenes (through regulation and direct provision) in such a way as to attain both a high degree of equity of access to health care, and to avoid the most significant forms of “market failure” that would arise in an unregulated private system.     

How Big is the Crowding-Out Effect of User Fees in the Rural Areas of Ethiopia? Implications for Equity and Resources Mobilization

Using a nested multinomial logit model, this study investigates the demand “reduction” and “diversion” effects of user fees in rural areas of Ethiopia. The results reveal that an increase in user fees of public clinics, which are the most widely used alternative, can have a significant demand reduction effect on the poorest of the poor. This implies that despite cost recovery has been advocated as an alternative means of health care financing in most of the developing world, increasing user fees may drive the poorest segment of the population out of the health care market unless some protective measures are taken.     

Supply-induced demand for medical services under price regulation: Evidence from hospital expansion in China

In 2009, China launched a nationwide reform to overhaul its enormous healthcare system. Subsequently, government spending on healthcare increased significantly. Simultaneously, public hospitals experienced rapid expansion. This study empirically examines whether supply-induced demand existed for public hospitals during the expansion process, based on hospital longitudinal data from 2007 to 2016, which is matched with individual patient data. We found that medical expenditure increased rapidly, while the quality of medical services did not change significantly during the hospital expansion. In addition, due to the price regulation of medical services, public hospitals mainly passed on the costs of expansion by inducing hospitalization and diagnostic over-testing. Furthermore, supply-induced demand was more obvious in diseases for which doctors had more asymmetric information. Based on the evidence provided in this study, the expansion of public hospitals has resulted in a waste of healthcare resources and a rise in the healthcare burden on patients. This has certain implications for further deepening the reform of public hospitals.     

The impacts of China's drug price zero-markup policy on medical expenditures and health outcomes

Drug overuse and high drug expenditures have long been of concern in China. In 2012, the Chinese government implemented the drug price zero-markup policy (ZMP) to contend with these problems. This paper investigates the impact of the ZMP on the hospitalization expenses and health outcomes of inpatients, using administrative data from Beijing. The findings show that the ZMP reduces inpatients' medicine expenses by an average of 20.4%, while total hospitalization expenses do not change significantly. The findings also show that the average length of hospital stay increases by 0.588 days. The results jointly indicate that hospitals adopt substitution behavior to make up for the drug revenue loss. The paper finds no evidence that the ZMP has a negative impact on patients' probability of death or readmission.     

The impacts of marketization and subsidies on the treatment quality performance of the Chinese hospitals sector

This paper investigates the treatment quality of the hospitals sector in China during 2009–2014. The treatment quality of a hospital is higher if relatively more medical services are provided with fewer deaths. Our research question is twofold: (i) Does the pressure of for-profit lower treatment quality by causing more deaths? (ii) Can government subsidy raise treatment quality by releasing the pressure from market competition? Our empirical results show that the treatment quality in China has been improving during the studied period. There are pieces of evidence that both marketization and government subsidies can boost the treatment quality of the hospitals sector. The co-existence of market force and government regulation is beneficial to the patients.     

Income-dependent impacts of health insurance on medical expenditures: Theory and evidence from China

Policymakers are interested in the impact of health insurance on individuals’ medical expenditures—not only the average effect for the overall population, but also the possible heterogeneous effects for subgroups. This paper focuses on the heterogeneous impacts of a nationwide health insurance program in China, the New Rural Cooperative Medical Scheme, on its enrollees’ out-of-pocket (OOP) expenditures for different income groups, since previous studies find no significant reduction in OOP for the general population. We firstly develop a theoretical model, showing that the reduction in OOP for the rich would be greater. Then, we test the theoretical prediction using a unique sample. The empirical finding is consistent with the model prediction, and the pattern of income-dependent impacts is robust to different estimation strategies.     

Job training and organizational performance: Analyses from medical institutions in China

The benefit of training on economic outcomes has been well-documented in previous literature, as training is generally recognized as one of the important approaches in human capital investment. However, the return of employee training on organizational level performance is not verified sufficiently, especially in the healthcare field. By taking advantage of a dataset with the information on all medical institutions in Sichuan, China over 2012–2016, this paper investigates the effects of employee training on medical institution’s performance through the Propensity Score Matching (PSM) method and the Event Study approach. The results show that training benefits medical institution performance in some indicators, such as total visits, outpatient visits, non-medical-insurance, and local competitiveness. These effects, however, vary across different types of medical institutions. Grassroot medical institutions in the county area that serve as a health gatekeeper (known as primary health care institution, PHCIs) gain most in hospital visits after training. In addition, training results in a 16.5% increase in the average performance wage for county-PHCIs, and a 52.8% increase in the employees’ performance wage for higher-level general hospitals in cities. In general, by participating in training, PHCIs in county region gain more in the overall revenue through the non-medical-insurance income.     

农民对农村公共服务投资的意愿分析——基于陕西关中地区24个乡镇102个村的调查

文章运用2007年7-9月陕西省关中地区24个乡镇102个村的调研数据分析了农民对农村公共服务投资的满意程度以及农民的投资意向。研究表明,农民对农村医疗卫生保健服务的满意度最低,但农民对农村医疗卫生保健服务的投资意愿却是很高的,仅次于农民对农村道路的投资意愿;而农民对文化娱乐公共项目投资的满意度和投资意愿都很低。因此,政府部门应该根据目前农民对农村公共服务项目的投资意愿,加大对农民不满意但又有强烈投资需求的项目的投入力度;对农民既不满意也不愿投资但与新农村建设相关的项目也应给予鼓励和支持。     

社区医疗卫生服务体系建设中的政府角色

在我国医疗卫生体制中,初级和二级医疗服务缺乏制度性的分工,导致民众大量的初级医疗卫生服务主要由医院承担,一方面造成医疗资源的浪费,另一方面也对医疗费用升高推波助澜。这一问题的症结在于,政府医疗资源大多流向各类医院。不同政府部门之间缺乏协调.社区医疗卫生服务体系有欠发达。政府增加投入以及各政府部门加强协调,引入医疗服务的守门人制度,是促进社区卫生服务发展的关键。