| [Purpose]This study evaluates the compensation effect of the critical illness protection system from the perspective of Universal Health Coverage(UHC),clarifies the functional positioning of critical illness insurance and critical illness medical assistance in UHC,and predicts the release of health service demand and medical treatment caused by the adjustment of compensation scheme parameters Based on the changes in costs,a linkage model of compensation plan parameter changes,guarantee effects,and fund expenditure scales was established,and a method for dynamically optimizing the compensation plan for the critical illness protection system was provided to supply theoretical and practical basis for improving the critical illness protection system and reducing poverty due to illness.[Methods](1)Policy review and literature research: Across literature search,learn about the medical insurance and medical assistance programs and their implementation status for critical illness in China and other countries,UHC-related theories,connotations and indicators.Using inductive summaries,systematically sort out the national,provincial and municipal policy documents related to critical illness insurance and critical illness medical assistance in recent years,and analyze the changes in macro policy orientation and the need for program adjustment brought by such changes.(2)Theoretical analysis: Use system theory,welfare economics theory,moral hazard theory and disease risk theory to analyze the positioning of critical illness insurance and critical illness medical assistance in UHC,build a scheme optimization model for the critical illness protection system,and determine the optimization principles.Use insurance actuarial theory to analyze the specific method of program adjustment.(3)Empirical research in sample areas: Select A county in Hubei Province and B county in Guizhou Province as sample areas,and collect critical illness insurance and critical illness medical assistance compensation policies of 2016,annual reports,medical insurance hospital settlement database,medical assistance compensation database,and patient survey questionnaires.(4)Statistical analysis: Descriptive statistical methods are used for preliminary analysis of survey data,and single factor T-test and chi-square test are used to compare the protection effects of different critical illness protection modes.Using the discontinuous time series model to evaluate the effect of critical illness insurance on reducing the burden of illness,combined with quasi-experimental research methods,it provides a reference for the improvement of the critical illness insurance system.The propensity score matching method and Probit model are used to control the main influencing factors of the population's medical behavior,such as age,gender,household attributes,disease code,severity,etc.,and remove the mixed offset of control variables and other observable factors to quantitatively measure The impact of changes in compensation schemes on the medical expenses of patients with serious illnesses,so as to analyze the impact on fund expenditures.The empirical frequency method is used to calculate the fund expenditure under different compensation parameters.[Results](1)The UHC guarantee effect of the current critical illness protection system compensation scheme in the sample area is limited.In terms of population coverage,the Critical Illness Protection Plan in Area B only covered 2.58% of the local hospitalized population.In terms of service coverage,the proportion of expenses in the medical insurance reimbursement catalogue for patients with critical illness in area A was only 77.41%,and the number of people discharged early for economic reasons accounted for 16.69%.Service underuse is more serious.In terms of cost coverage,the out-of-pocket expenses of patients with critical illnesses in both places exceeded 20,000 yuan,and the proportion of patients suffering from poverty due to illness exceeded 60%.The medical debt ratios of the two places also reached 65.90% and 72.86%,respectively in higher level.Discontinuous time series results show that patients' out-of-pocket expenses show an upward trend after reform(= 5.906,P <0.05).The effective reimbursement ratio decreased after the intervention(=-0.100,P <0.01),and critical illness insurance did not effectively reduce the financial burden on patients.(2)The goal of the dynamic optimization of the compensation scheme is to solve the poverty caused by disease.During the adjustment process,the principles of fairness,efficiency,sustainability,unity and connection,and relative stability and dynamic adjustment should be followed to build the "compensation parameter-UHC proctection effect-"Fund Expenditure" dynamic optimization model to gradually optimize the critical illness insurance and critical illness medical assistance programs.(3)Optimization of the critical illness insurance scheme can improve the effectiveness of UHC protection.The reduction of the critical illness insurance payment line can effectively improve the UHC's population coverage effect.For example,in the case of the B area lowering the original threshold by 20%,the population covered by the critical illness insurance has doubled(5.43%),which has greatly increased.To cover the crowd.The proportion of reimbursable expenses after the simulation of Area A was included in the negotiated drugs increased by 5.91%,and the service coverage effect was significantly improved.With the increase in the reimbursement rate for critical illness insurance,the degree of solution to poverty caused by patients can reach 30%.Optimizing the medical assistance plan for serious diseases can promote fair benefits.The results of the benefit attribution analysis show that,with the same degree of solution to poverty caused by disease,compared to considering only the cost level,the assistance plan that uses the proportion of household income and out-of-pocket expenses as the inclusion standard is conducive to reducing the gap between the rich and the poor.Its concentration index is negative,and the poor benefit more.Poverty caused by illness is still limited after the optimization of the critical illness protection scheme.In simulation calculations,we found that no matter how the two critical illness protection schemes are adjusted,it is difficult to solve the problem-caused poverty by more than 30%.This is because nearly 20% of the patients in the household survey belong to the subsistence allowance households or the poor people who set up files.In view of this phenomenon,serious illness protection cannot be resolved,and social assistance,such as the payment of living allowances,should be used to alleviate it.(4)The adjustment of the critical illness insurance plan is limited by the local funding.With the reduction of the payment threshold and the increase in the reimbursement ratio,nearly one-third of the critical illness insurance program funds in the two places began to exceed the local funding.The per capita fund expenditure of some programs in Area A even reached 65 yuan,exceeding the local maximum funding standard of 50 yuan,and the gap between the two brought a greater burden on fundraising.(5)Changes in the critical illness protection plan will lead to the release of demand for health services.The propensity score matching showed that after controlling for factors such as gender,age,length of hospital stay,and family attributes,the change in the critical illness insurance program led to an increase in the medical expenses of patients with critical illness by 6,660.390 yuan.After deducting the natural growth rate of GDP,the plan adjustment led to the total medical expenses of local patients The growth rate was 2.47%,and changes in the critical illness protection program caused the release of demand for health services.When calculating the critical illness insurance fund expenditure,the particularity of the disease should be considered,and the insurance factor should be calculated based on historical data.[Conclusions]The current critical illness protection compensation scheme has many problems and the UHC guarantee effect is very limited.It is imperative to dynamically optimize the critical illness protection system compensation scheme.When optimizing the critical illness insurance plan,we should pay attention to population coverage,carefully adjust the payment threshold in conjunction with the local medical insurance fund,try to increase the proportion of critical illness insurance reimbursement,and increase the cost coverage effect.When optimizing the medical assistance plan for serious diseases,we should proceed from the fairness,take the ratio of income to out-of-pocket expenses as the inclusion standard,unify and increase the assistance ratio,and effectively play the bottom role.Strengthening the connection between critical illness insurance and critical illness medical assistance should actively play the role of social assistance for patients suffering from poverty due to illness that cannot be resolved by the optimization of the critical illness protection system compensation scheme.When calculating the expenditure of a program fund,consider the changes in demand for health services caused by program changes and scientifically calculate the insurance factor.At the same time,considering the impact of the external environment on fund expenditures,adding adjustment factors for payment method reforms to measure fund expenditures under different compensation schemes.When choosing a plan,the local economic development level and fund-raising level should be considered,and a "cost-effectiveness" evaluation should be adopted to integrate the three aspects of UHC guarantee and select an appropriate compensation plan.The adjustment of the compensation plan for the critical illness protection system should be scientific and step-by-step.The current compensation plan should be dynamically adjusted in an orderly manner based on the adjustment model and historical data to better solve the poverty caused by the disease.[Innovation and Deficiency]Research innovation:(1)The research content is innovative: it breaks through the limitation of analyzing the guarantee effect of a single medical security system,and analyzes the combined guarantee effect of major illness medical insurance and major illness medical assistance.We will break through the limitation of static research in the past and dynamically optimize the compensation plan for the critical illness protection system.(2)The research method has been extended: from the individual level,the comparison of the protection effect of major illness before and after the adjustment of the plan through the tendency score matching method can eliminate heterogeneity and control confounding factors.The comprehensive use of medical insurance actuarial methods to predict the scale of fund expenditure for different major medical insurance compensation models from the group level.Organically combine the patient household survey database with the local NCMS database.The patient survey database is used to evaluate the effectiveness of the current compensation scheme UHC and determine the compensation scheme parameters according to policy objectives,to solve the problem that many UHC evaluation index values involve family income variables.The overall NCMS database is used to measure the scale of fund expenditures with different compensation parameters,which is more in line with actual conditions and provides an effective reference for adjusting supplementary programs.(3)The research perspective has characteristics: from the three dimensions of UHC coverage of population,coverage of service,and coverage level,a more systematic analysis of the protection effect of the critical illness protection system.The discussion of the critical illness protection system from the breadth and depth of poverty alleviation has enriched the research perspective.Limitations and Prospects:In the process of calculating the insurance factor formula using the propensity score matching method,because the variables in the NCMS system are limited,some variables that may have an impact on medical costs,such as patient education and number of years of illness,are not included.With the further improvement of the medical insurance system,these variables will be included one by one in the future.Secondly,this study does not have relevant data before and after the payment method reform.The increase in fund efficiency brought about by the payment method reform is based on literature research.In order to more accurately design and optimize solutions,relevant data can be collected in the future and more accurate calculations can be performed on this part.The database used in this study is the 2016 Hospitalization Compensation Database.The problem of excessively high out-of-medicine expenses in the results revealed in the results may gradually be resolved with the inclusion of multiple negotiated drugs in 2017-2019.Follow-up can be verified with the latest database in the area.Given that Hubei and Guizhou are only representative regions in the central and western regions and cannot represent the situation in developed regions,the results and conclusions of this study can only explain regions with comparable levels of economic and social development,and other regions have yet to be studied. |
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