| Objective:Through the study of domestic and foreign medical insurance policies and measures, we analyzed the hospitalization disease records and expenditures of medical insured government employees and workers (MIGEW) in Changsha city from April 1,2002 to December 31, 2006 with the theory of health statistics and health economics in order to probe its affected factors and provide scientific data to further reform and improve the medical insurance system.Methods:The samples of in-patients of MIGEW from April 1,2002 to December 31,2006 were drawn out from the data of Hunan Provincial Medical Insurance Fund Center (HMIFC),102,828 patients were selected as the study population after strict data checking and screening. The "case" was the study unit which meant person-time of patients who left hospitals. If the same patient lived in hospital many times, it will be counted for different person-times. With the method of stratified random sampling, 8,550 cases were drawn out to compose the study samples from the MIGEW population according to the years of patients left hospitals.According to ICD-10 diseases classified standards and analyzed samples of diseases composition, we carried out the person-time hospitalization expenditure univariate analyses of different sexes, age groups, work statues, unit sorts, hospital grades, years and disease types. The analyses of gradual multivariate linear regressions were done based on dependent variable of person-time hospitalization expenditures and independent variable of sexes, age groups, work statues, unit sorts, hospital grades, years, treatment effects, operations, hospitalization days as well as ICD-10 disease categories. The descriptive analyses were done based on government-paid and out of pocket proportions in accordance with yearly groups of patients out of hospitals, ICD-10 disease categories and hospital grades. The out of pocket proportion univariate analyses were done based on sexes, ages, officials at different levels and other possible factors as grouped variables, and out of pocket proportion as dependent variables. The analyses of gradual multivariate linear regressions were done based on out of pocket proportion as dependent variable, and sexes, age groups, officials at different levels, work statues, unit sorts, subordinative units, hospital grades, years, operations, if or not serious diseases and hospitalization days as independent variables in order to discuss the main affected factors of out of pocket proportion. The data envelopment analysis was applied for evaluating medicare efficiency, the gray forecast was used for analyzing the population data of per-time average expenditures from 2002 to 2006, and the path analysis was used for discussing the affected factors of per-time average expenditures.The study was analyzed and evaluated by statistic analyses and health economic evaluations, including descriptive statistic analysis, univariate analysis, gray forecast, data envelopment analysis, path analysis and so on. The analytic software used in the study including Excel 2003, SPSS 15.0, SAS9.13 and Matlab6.5.Results:1. Analysis of hospitalization disease category. The chronic diseases of circulatory system, respiratory system, tumor, digestive system and urogenital system were the top 5 diseases of medical insured in-patients. The disease composition of different male age groups showed that circulatory system, respiratory system, digestive system diseases were the main diseases of every male age group. Digestive system disease was the main disease of the male ages below 45, accounted for 27.5%. Circulatory system disease was the main disease of the male ages from 45 to 59 and 59 above, accounted for 21.8% and 33.9% respectively. The diseases of circulatory system, urogenital system, digestive system and tumor were the main diseases of every female age group. Among them, urogenital system disease was the main disease of the female ages below 45, accounted for 25.7%, circulatory system disease was the main disease of the male ages from 45 to 59 and 59 above, accounted for 19.1% and 38.0% respectively. The two big diseases of digestive system and tumor became the second and third diseases in the three age groups.2. Analysis of hospitalization expenditures. All there were statistical significance of the difference of per-time total average hospitalization expenditures, monitoring and nursing fees, treatment costs, drug fees and general medical service charges (P<0.05), basically each expense of males' was higher than females'. There were no statistical significance of checking and assay fees and material costs between male and female patients. There were statistical significance of the difference of per-time total average hospitalization expenditures, monitoring and nursing fees, checking and assay fees, treatment costs, drug fees and general medical service charges (P<0.05) in different groups of various aged patients. Compared with the two, the results showed that highest cost of every fee basically was 59 years old group. There were statistical significance of the difference of per-time total average hospitalization expenditures, monitoring and nursing fees, checking and assay fees, treatment costs, drug fees and general medical service charges (P<0.05) between different groups of patients in various working statues, and every fee of the retired patients was higher than the patients in service.. There were no statistical significance of the difference between the retired and the patients in service in material costs. There were statistical significance of the difference of checking and assay fees, treatment costs, material costs and drug fees (P<0.05) in different groups of unit sorts. There were no statistical significance of the difference of per-time total average expenditures, monitoring and nursing fees and general medical service charges in corporations, non-business organizations and administrations. Basically, the highest cost of every expenses occurred in three-grade hospital, and second in two-grade hospital, and the lowest in one-grade hospital. There were statistical significance of the difference of per-time total average expenditures, monitoring and nursing fees, checking and assay fees, treatment costs, material costs, drug fees and general medical service charges (P<0.05) between the patients in various groups of years. In general, the tendency of every proportion of hospitalization expenditures went up each year. According to the hospitalization patient-time, the top 5 diseases of ICD-10 disease categories were circulatory system (25.50%), digestive system (15.02%), tumor (11.10%), respiratory system (10.95%) and urogenital system (9.22%). The top 5 diseases of hospitalization expenditures were circulatory system, tumor, digestive system, respiratory system and urogenital system. Although the order of total hospitalization expenditures varied yearly, the five diseases were all in the top 5. The top 5 diseases of per-time average expenditures ordinally were tumor, blood and hematopoietic organ diseases, factors of influencing health statues and contacting with healthcare units, neural system diseases, endocrine diseases, nutrition and metabolism diseases. The lowest 5 diseases of per-time average expenditures ordinally were dermatosis and hypodermic tissue diseases, external factors of diseases and deaths, respiratory system diseases, urogenital system diseases, congenital abnormalities, denaturalization and chromosome abnormities. The four diseases of the digestive system, tumor, urogenital system and circulatory system were the mutual diseases in the top 5 in every age group. The diseases of muscle skeletal system and connective tissues were the main diseases of middle aged people (45-59 years old). Compared with the high and low cost diseases of hospitalization expenditures, drug fees accounted for a big proportion of them, and operation and material fees just accounted for a small proportion of them. Compared with other every factor of hospitalization expenditures, there was statistical significance of the difference of subordinative units, treatment effects, operation effects, hospitalization days. The analysis on hospitalization expenditures with multivariate linear regressions showed that the seven factors such as sexes, age groups, hospital grades, years, ICD-10 disease categories, operations and hospitalization days were the main effective factors except the working statues, subordinative units and treatment effects.3. Out of pocket analysis of hospitalization expenditures. There were no statistical significance of the difference between yearly government-paid and out of pocket. According to the standards of ICD-10 disease categories, the highest five diseases of per-time average self-paid were pregnancy, childbirth and childbed diseases (46.54%), ophthalmic diseases (44.90%), congenital abnormalities, denaturalization and chromosome abnormities (43.55%), ear and papillary diseases (35.90%), external factors of diseases and deaths (34.58%). The lowest three diseases were respiratory system diseases (27.91%), blood and hematopoietic organ diseases (26.71%), neural system diseases (26.49%). The highest five diseases of per-time average out of pocket expenditures were tumor (ï¿¥2,691.36), blood and hematopoietic organ diseases (ï¿¥2,570.21), pregnancy, childbirth and childbed diseases (ï¿¥2,568.78), congenital abnormalities, denaturalization and chromosome abnormities (ï¿¥2,240.19), symptoms, somatogenies, clinical and laboratory abnormalities (ï¿¥2,174.30). The highest five diseases of government-paid expenditures were circulatory system diseases (ï¿¥12,114,500), tumor (ï¿¥6,809,200), digestive system diseases (ï¿¥5,819,200), respiratory system diseases (ï¿¥3,631,800), urogenital system diseases (ï¿¥3,098,400). The out of pocket proportion of hospitalization was 22.32% in one-grade hospital, 24.33% in two-grade hospital,32.40% in three-grade hospital, and this meant that the more grades hospital had, the higher expenditures patient paid. The result of multivariate linear regressions showed that the main affected factors of out of pocket proportion were sexes, age groups, official levels, working statues, unit sorts, subordinative units,hospital grades, years, operation effects, if or not suffered serious diseases, hospitalization days.4. The result of data envelopment analysis showed that F matrix got the relative virtual value of decision-making unit 1,3,4,5 equal to 1, it was effective as weak DEA (Output-C2R), decision-making unit 2 was effective as non-weak DEA (Output-C2R). R matrix got no changes of the scale incomes of decision-making unit 1,3,4,5, the scale incomes of decision-making unit 2 increased step-up. Rr matrix got no weak crowded phenomena of the decision-making unit 1,2,3,4,5, the output of the decision-making unit 1,3,4,5 was the biggest while invested, the scale incomes of decision-making unit 2 increased step-up, and the five decision-making units would not appear the phenomena of input decrease and output increase on contrary. The above-mentioned showed that except 2003 the investment of Hunan Provincial Medical Insurance got a very good output from 2002 to 2006. The cure and recovery rates of patients in medical insurance appointed hospitals should be brought into the evaluation targets so as to further elevate the efficiency of investment.5. The result of grey forecast showed that according to the developed tendency of 2002 to 2006, the per-time average hospitalization expenditures of MIGEW in Changsha were dropped yearly from 2006, and this also reflected the efficiency of medical insurance achievements, and the payout of medical insurance would be declined on a higher level.6. Path analysis showed that there were two obvious paths to influence the per-time average expenditures. One was hospitalization days to per-time average expenditures, the other was out hospital diagnosis, hospital grades, ages, sexes, if or not operations, unite sorts to per-time average expenditures, and among them controllable factors could reduce hospitalization expenditures and out of pocket proportion through shortening hospitalization days.Conclusions:1. There were common and difference of the same diseases in medical insured in-patients of various sexes and age groups. The chronic diseases of circulatory system, respiratory system, tumor, digestive system and urogenital system were the main diseases of medical insured in-patients, but there were differences in patient composition.2. The hospitalization patients of different sexes, age groups, working statues, unit sorts, hospital grades, years and diseases were the affected factors of hospital expenditures.3. The three diseases of the most expensive total hospitalization expenditures, the most population of hospitalization person-time and the highest hospitalization expenses paid by government were circulatory, tumor and digestive system diseases. The main affected factors of per-time average hospitalization expenditures were sexes, age groups, hospital grades, years, ICD-10 diseases, operations and hospitalization days. The per-time average hospitalization expenditures of diseases were higher while the longer the hospitalization days, the higher the hospital grades and ages as well as hospitalization expenditures occurred. The per-time average expenditures of operations were higher than that of non-operations. The per-time average hospitalization expenditures of males were higher than that of females, and the tendency of per-time average hospitalization expenditures went up yearly.4. Drug fees accounted for a big proportion of hospitalization expenditures, the highest drug fee of tumor accounted for 57.92%.5. The top five out of pocket diseases were pregnancy, childbirth and childbed, ophthalmic diseases, congenital abnormalities, denaturalization and chromosome abnormities, ear and papillary diseases, and external factors of diseases and deaths. The higher the grade hospital got, the higher out of pocket proportion resulted in.6. The results of data envelopment analysis showed that except 2003 the output effects invested by Hunan Provincial Medical Insurance from 2002 to 2006 were very good. According to the grey forecast of 2002-2006 developed tendencies, we found that the per-time average expenditures declined stably from 2006, and the result showed that the medical insurance got effects. Path analysis showed that there were two obvious paths to influence the per-time average expenditures. One was hospitalization days to per-time average expenditures, the other was out-hospital diagnosis, hospital grades, ages, sexes, if or not operations, unite sorts to per-time average expenditures. Under the guarantee of medical quality, shortening invalid hospitalization days to reduce hospitalization expenditures and out of pocket proportion is a controllable factor and the key to control total hospitalization expenditures. |
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