Abstract摘 要 背景和目的： 近年来，医疗费用的快速增长和医保基金的入不敷出，已成为世界各国医疗保险面临的共同问题。如何控制医疗费用是解决这个难题的核心。目前，我国医疗保险制度改革虽然取得了长足进展，但是在住院费用的控制上也暴露出诸多问题，医疗费用的负担过重，仍然是造成部分群众贫困的重要原因之一。现在，大家关注的费用控制重点多在医疗总费用的控制方面，而对于适合医疗保险操作的病种费用没有比较全面的探讨。 住院费用是构成医疗总费用的主体，对住院费用的有效控制已成为遏制医疗费用过快增长的的关键。在目前已有的医疗保险政策框架下，从医保主体的医疗服务提供方、参保人群和医疗保险承办方来看，作为医疗服务提供方的医院，实施对享有医保患者住院费用的控制效果最为明显。为了更好了解医疗保险政策对患者就医行为以及就医方式的影响，有必要对医保患者与自费患者住院费用差异性做出分析。从而为医疗机构增强医疗费用控制意识，完善医疗费用控制机制，调整医疗费用结果，切实做到合理检查、合理用药、合理治疗提供理论依据。 因此，为有效控制住院费用的快速增长，降低医疗成本，需要分析住院费用中的住院天数、治疗费、药费、护理费、手术费等各项影响因素，加强对住院费用及其影响因素的研究，提高医疗费用控制措施的研究，探索医疗保险制度对控制住院费用的作用，旨在为控制住院费用和医疗费用过快增长和深化医疗体制改革提供参考。 本研究通过对比陕西省某三级甲等医院医保患者与自费患者的住院费用，分析其各项构成差异，探讨医疗保险制度对患者住院费用的影响，为降低医疗成本、控制医疗费用过快增长和提高医疗服务质量提供依据。 对象与方法： 首先，抽取陕西省某三级甲等医院2014年9月1日至2015年8月31日期间，满足条件的4种常见病种：糖尿病、冠状动脉性心脏病、缺血性脑瘁中、乳腺癌病中的医保及自费患者980例，对其住院费用实施对比分析，统计医疗总费用、住院天数、护理费、床位费、药费、化验费、治疗费、输血费、检查费、诊疗费、调温费、麻醉费、放射费、手术费、其他费用的分布和构成情况。其次，将4个病种的患者按其结算方式是医保还是自费进行分类。第三步按配对的原则进行配对，在配成对的患者中分别编号，给与随机数，最终选择其中随机数最小的前10对。 本研究严格按照抽样要求从“医院出入院信息管理系统”中，调取出医保患者和自费患者的住院号、姓名，筛选出每个研究对象的数据。对医保患者和自费患者按照社会人口学特征，如：性别、年龄、婚姻状况、职业；住院情况，如：疾病构成、住院天数、出院情况以及住院费用及其构成三个方面进行统计分析。首先，是按数据类型分别计算相应的统计量和绘制相应的图表进行描述性分析。计量资料采用均数、标准差等指标进行统计描述，计数和等级资料采用率、百分比等相对数指标进行描述。两独立样本均数的比较采用t检验，不满足正态性的数据采用非参数检验的秩和检验。对分类资料，对结果无序的资料的比较采用?2检验，对结果有序的资料的比较采用秩和检验，检验水准均取?=0.05。相关图表用Microsoft Excel绘制完成。 结果： 1. 980例医保和自费患者中，糖尿病、冠心病、脑梗塞、乳腺癌分别为280、236、220和244例，其中，女性患者656例，占66.9%；男性患者324例，占33.1%。年龄构成分析显示，18~40岁79例，占8.1%；41~60岁366例，占37.3%；而60岁以上535例，占54.6%。四种病种患者中，总治愈率和好转率合计96.2%，未治愈和死亡率合计3.8%，其中医保患者治愈和好转率合计95.7%，未愈和死亡率为4.3%；而自费患者治愈和好转率为96.6%，未愈和死亡率为3.4%。 2. 四种病种患者平均住院天数为15.05±6.04天，其中，医保患者15.20±6.11天，自费患者15.00±6.09天。不同病种分析显示糖尿病和脑梗塞医保和自费患者住院天数比较无统计学差异（P＞0.05），而冠心病医保患者住院天数长于自费患者，而乳腺癌医保患者住院天数短于自费患者（P＜0.05）。 3. 四种疾病患者平均住院费用14737±1863元，自费患者为18905±1985元，医保患者为10559±1776元，所有研究对象及不同病种中自费患者住院费用均明显高于医保患者（P＜0.05）。 4. 不同病种医疗费用构成不同，其中，糖尿病医保患者药费、治疗费、输血费、调温费显著低于自费患者（P＜0.01）；冠心病医保患者药费、治疗费、输血费、诊疗费、麻醉费、放射费和手术费均低于自费患者（P＜0.01）；脑梗塞医保患者在药费、治疗费、调温费、麻醉费和手术费均低于医保患者（P＜0.01）；乳腺癌中医保患者治疗费、输血费、检查费、麻醉费和手术费显著低于自费患者，但药费显著高于医保患者（P＜0.01）。 结论： 1. 医保患者和自费患者总体预后基本一致，但在不同病种间住院时间不同。 2. 不同病种之间医疗费用差别较大，住院总费用自费患者高于医保患者。 3. 不同病种之间住院费用构成不同，内科主要以药物和治疗费用为主，而外科中除药物和治疗费用外，手术和麻醉费用也占比较大。 建议： 1. 减少医疗服务的诱导需求以及过度利用。 2. 分析医疗费用的影响因素，实现医疗资源合理利用。 3. 积极开展医药卫生体制改革。 4. 鼓励实额预算的预付制。 5. 引进竞争机制，加强预防保健工作。 6. 分科室实施费用管控措施。 7. 加强医德医风建设。
ABSTRACT Background and Objectives: In recent years, the rapid growth of medical costs and health insurance funds making ends meet have become a common problem faced by health insurance in world. How to control health care costs is the key to solve this problem. At present, the reform of China's medical insurance system has made considerable progress, but in the control of hospitalization costs still has many problems. The heavy burden of medical cost remains one of the important reasons for poverty in some people. Now, we are focused more in the control of total health care costs but without a comprehensive exploreation of diseases cost which suitable for health insurance. Hospitalization costs is the main part of total health care cost, the effective control of hospitalization costs has become a key to curb the excessive growth of medical costs. Under the current framework of existing health insurance policy and from the view of health care providers, health insurance and the insured population organizer, the hospital as a health care provider, has a obvious effect to control the hospitalization costs. To better understand the impact of health insurance policies on patient care seeking behavior and the way of medical treatment, it is necessary to make an analysis of the differences of hospitalization costs between the medicare patients and private patients. It will provide a theoretical basis to enhance awareness of medical costs control, improve health care cost control mechanism, adjust the results of medical costs, and make sure the reasonable inspection, drug using and treatment. Therefore, in order to effectively control the rapid growth of hospitalization costs and reduce health care costs, we need to analyze the influencing factors of length of stay in hospital, treatment fees, medicine fees, nursing care fees and surgical fees, trengthen the research in the influencing factors of hospitalization costs and the measures for improving medical costs control, and explore the role of medical insurance system in controlling hospitalization costs. These will provide a reference for controlling hospitalization costs and excessive growth of medical costs, and deeply reforming the medical care system. This study aim to compare the hospitalization costs between medicare patients and private patient in a third-level grade A hospital of Shaanxi province, to analyze its differences of each part of hospitalization costs, and to explore the effect of medical insurance of the hospitalization costs. The study will provide the basis for reducing medical costs, controlling the excessive growth of medical costs and improving the quality of medical services. Subjects and methods: Firstly, 980 medicare and private patients with diabetes, coronary heart disease, ischemic brain weary, the breast cancer were selected from a third-level grade A hospital of Shaanxi province from September 1, 2014 to 31 August 2015. We conduct a comparative analysis of the distribution and composition of hospitalization costs, including the total hospitalization costs, length of stay, and the fees of nursing care, bed, medicines, laboratory test, treatment, blood transfusion, examination, thermostat, anesthesia, radiology, operation, and other expenses. Next, we classified the patients with four disease according to their way of payments into medicare and private patients. We exported the patient number, name of medicare and private patients, and selected data for each study subject from the “hospital admission and discharge information management system” strictly according to the requirements of the sampling. We analyzed the data of the subjects according to sociodemographic characteristics, such as: gender, age, marital status, occupation; hospitalizations, such as: kinds of disease, length of stay and discharge; as well as the hospitalization cost and its components. Firstly, calculate the appropriate statistics and draw graphs respectively according to the type of data. The measurement data was used mean, standard deviation for statistical description, the count and grade data was used rate, percentage and other relative number for description. Two independent samples were compared using t test, if it does not meet the normality, then we used the non-parametric rank sum test. We compared the categorical data and disordered materials using ?2 test. The significant level was taken as ? = 0.05. Related charts were made by Microsoft Excel. Results: 1. There were 280,236,220 and 244 cases which were with diabetes, coronary heart disease, cerebral infarction, breast cancer, respectively in 980 medicare and private patients. Of which 656 cases were female patients, accounting for 66.9%; 324 cases were male patients, accounting for 33.1% . Age composition analysis showed that 79 cases were in 18 to 40 years old, accounting for 8.1%; 366 cases were in 41 to 60 years, accounting for 37.3%; and 535 cases were beyond 60 years old, accounting for 54.6%. In four kinds of disease, the total cure and improvement rates were 96.2 %, the not healed and mortality rates were 3.8%; of which total cure and improvement rates were 95.7% in medicare patients, not healed and mortality rates were 4.3%; the total cured and improvement rates were 96.6% in private patients, and the not healed and mortality rates were 3.4%. 2. the average length of stay of hospitalization in patients with four kinds of disease was 15.05±6.04 days, in which medicare patients was 15.20±6.11 days and private patients was 15.00±6.09 days. The analysis in different diseases showed no significant difference of length of hospitalization stay between medicare patients and private patients with diabetes and cerebral infarction (P>0.05), but the length of hospitalization stay in medicare patients was longer than paivates patients with coronary heart disease, while it in medicare patients was less than paivates patients with breast cancer (P<0.05). 3. The average hospitalization costs in all patients of four diseases were 14737±1863 yuan, and in private patients were 18905±1985 Yuan, in medicare patients were 10559±1776 yuan, the average hospitalization cost in private patients were higher than medicare patients in all subjects and in different diseases (P<0.05). 4. The hospitalization costs constitute was different in four kinds of diseases, where the fees of medicine, treatment, blood transmission and thermostat in medicare patients with diabetes were significantly lower than private patients (P<0.05); the fees of medicine, treatment, blood transfusion, anesthesia, radiology and operation in medicare patients with coronary heart were significantly lower than private patients (P<0.05); the fees of medicine, treatment, thermostat anesthesia, and operation in medicare patients with cerebral infarction were significantly lower than private patients (P<0.05); the fees of treatment, blood transfusion, inspection, anesthesia and operation in medicare patients with breast cancer were significantly lower than private patients, but in medicine fees were significantly higher than private patients (P<0.05). Conclusion 1. The overall prognosis in medicare patients and private is basically same, but the length of hospitalization stay was different among different diseases. 2. The difference of medical costs was significant in different diseases, the total hospitalization costs in private patients was higher than medicare patients. 3. The hospitalization costs constitute was different in different diseases, the medicine and treatment fees were main parts in the internal medicine and surgical department, in addition, the operation and anesthesia fees also were a larger proportion in surgical department. Suggestions: 1. Reduce medical induced demand services and excessive use. 2. Analyze the influencing of medical costs, realize the rational use of medical resources. 3. Carry out medical and health system reform . 4. Encourage the prepaid system based on real budget. 5. Bring in the competition mechanism, strengthen preventive health care system. 6. Implement sub-departments cost control measures. 7. Strengthen the medical ethics.