I 新农合方案调整对农村老年人健康绩效的影响研究 —基于宁夏医改样本县的面板数据分析 摘要 目的：本研究利用“创新支付制度，提高卫生效益”项目的调查数据，分别从主观 健康和客观健康两个维度来分析新农合方案调整对试点县老年人健康状况的影响，从总 体水平和不同收入水平两个方面计算新农合政策调整对老年人健康的净效应，进而分析 政策调整对老年人健康绩效的影响，为促进宁夏统筹城乡医疗保障制度健康持续发展提 供政策依据。 方法：运用样本县 2009、2011 、2012 和 2015 年四年的面板数据，以样本县常驻 （居住 6 个月及以上）60 岁及以上老年人为研究对象，在倾向得分匹配的基础上运用倍 差法模型分析新农合方案调整对农村老年人健康状况的净效应。用多阶段 DID-Logit 模 型进一步分析宁夏医改试点项目在实施过程中对不同收入老年人健康水平的递进性影 响。通过计算边际效应分析新农合政策调整对老年人的健康绩效。 结果：（1）四次调查，干预组和对照组老年人的两周患病率均有降低趋势，干预 组老年人在 2009、2011、2012 和 2015 年的两周患病率分别为 41.7%、27.6%、29.3%和 26.0%，对照组分别为 31.4%、30.7%、25.5%和 22.0%，至 2015 年，干预组和对照组比 干预前分别降低了 15.7%和 9.4%。慢性病患病率在干预后的第一年两组均有所下降， 2012 年开始上升，至 2015 年，干预组与对照组较干预前分别上升了 9.2%和 12.8%。自 评健康方面，对照组的自评健康良好率呈不稳定性波动，干预组呈稳定上升趋势。（2） 双重差分结果显示，从两周患病率看，2011 年、2012 年和 2015 年，政策实施后干预组 老年人的两周患病率分别降低了 11.1%、5.5%和 5.7%，即政策的实施对干预组老年人的 两周患病率起到持续性降低的作用，且见效快。从慢性病患病率看，在政策干预一年后 和三年后，干预组老年人的慢性病患病率均有所降低，但效果并不显著，干预六年后，宁夏医科大学硕士学位报告 中文摘要 II 慢性病患病率有升高，但依然不显著，即政策的调整对干预组老年人的慢性病患病率无 显著影响。此外，新农合方案调整对干预组老年人的自评健康在政策实施初期效果不明 显，在实施三年后和六年后，干预组老年人的自评健康良好率比对照组老年人分别增加 了 8.8%和 9.2%，干预效果具有一定的滞后性。（3）对不同收入组老年人而言，新农合 支付制度改革政策的健康绩效主要体现在中低收入组、中等收入组和高收入组老年人， 在低收入组和中高收入组老年人中未体现。新农合方案调整对中低收入组老年人的健康 改善主要体现在对主观健康的影响，政策调整后，该收入组老年人的自评健康良好率在 政策实施一年、三年和六年后分别增加了 15.3%、25.0%和 14.9%。新农合方案调整对中 等收入组老年人的健康改善主要体现在对客观健康的影响，政策调整后，该收入组老年 人的两周患病率在政策实施一年、三年和六年后分别降低了 18.0%、17.6%和 12.4%。对 于高收入组老年人，新农合方案调整后，该组老年人的两周患病率仅在项目实施一年后 降低了 14.0%，此后不再显著。但政策的调整使得该组老年人自评健康良好率在政策实 施三年和六年后分别增加了 16.8%和 14.5%。 结论：（1）新农合政策调整后干预县老年人的两周患病率降低，政策效应快，且具有 持续性。（2）新农合政策调整对干预县老年人慢性病患病率的降低作用不明显，政策 效应不显著。（3）新农合政策的调整改善了干预县老年人的自评健康，但改善作用在 干预三年后逐渐显现，反映了政策调整对主观健康的滞后作用。（4）对于不同收入层 次老年人而言，新农合政策的健康绩效主要体现在中低收入、中等收入和高收入组老年 人中，在低收入组和中高收入组老年人中未体现。 关键词 新型农村合作医疗，农村老年人，健康绩效宁夏医科大学硕士学位报告 英文摘要 III Study on the Effect of the New Rural Cooperative Medical Scheme Adjustment on the Health Performance of Rural Elderly —Based on Panel Data in Sample County of Ningxia Medical Reform ABSTRACT Objective To investigate the impact of the New Rural Cooperative Medical Scheme (NCMS) adjustment on the health status of the elderly in the pilot counties, adopting the data of the “Innovative Payment System and Improving Health Benefits” project to analyze subjective health and objective health of the elderly, and also evaluate the health net effect of the policy adjustment from the overall and different income levels, so as analyzing the impact and its magnitude of the policy adjustment on the health performance of the elderly, and providing the useful policy evidence for promoting the sustained development by medical security policies of the overall plans on urban and rural in Ningxia. Methods Using the panel data of four counties in 2009, 2011, 2012 and 2015 years, the elderly in the sample counties （residential 6 months and above） aged 60 and older were studied. Based on the matching of propensity scores, the Difference-in-Difference model (DID) was used to analyze the net effect of the NCMS on the health status of rural elderly. The multi-stage DID-Logit model has been applied into the study to further analyzeits dynamic changes of its multiple stages and the progressive effects on the health of different incomes in the implementation process, and the health performance of the NCMS adjustment for the elderly analyzed by calculating the marginal effect. Results （1）During the four survey years, the two-week prevalence rate of the elderly in the intervention group and the control group decreased. The prevalence of the elderly宁夏医科大学硕士学位报告 英文摘要 IV among the intervention group in 2009, 2011, 2012 and 2015 were 41.7% ,27.6% ,29.3% and 26.0% , the control group were 31.4%, 30.7%, 25.5%, and 22.0%, respectively. By 2015, the two-week prevalence rate of the intervention group and the control group were reduced by 15.7% and 9.4% than before. The prevalence of chronic diseases decreased in both groups after the intervention, and began to rise in 2012. the intervention group and the control group increased by 9.2% and 12.8% in 2015. respectively, compared with the baseline survey. In terms of self-evaluation health, the self-evaluation health rate of the county was unstable, and the intervention group showed a steady upward trend. （2）The DID results showed that the implementation of the policy reduced the prevalence of the two-week elderly in the project counties by 11.1%, 5.5% and 5.7% respectively，in 2011, 2012 and 2015. That is to say, the implementation of the policy has a sustained reduction in the two-week prevalence rate of the elderly in the intervention group, and the policy effect is effective; In terms of the prevalence of chronic diseases, the chronic disease prevalence of the elderly in the intervention group decreased after one year and three years of policy intervention, but the effect was not significant. After six years of intervention, the prevalence of chronic diseases increased. However, it is still not significant, indicating that the adjustment of policies has no significant effect on the prevalence of chronic diseases in the intervention group. In addition, the NCMS adjustment effect on the self-rated health of the elderly in the intervention group was not obvious at the initial stage of the policy implementation. After three years and six years of implementation, the elderly in the intervention group increased by 8.8% and 9.2% respectively compared with the control group, in terms of self-rated health, the policy effect has a certain lag.（3）For the elderly in different income groups, the adjustment of the NCMS improved the health of the elderly in middle-low income group, the middle-income group and the high-income group, and had no significant effect on the low-income group and the middle-high income group. The effect of the adjustment of the NCMS on the health宁夏医科大学硕士学位报告 英文摘要 V improvement of the middle and low-income group is mainly reflected in the subjective health. As a result, the self-rated health of the group increased by 15.3%, 25.0% and 14.9% respectively one year, three years and six years after the implementation of the policy. The adjustment of the NCMS to the health of the middle-income group is mainly reflected in the objective health effects, which reduced the two-week prevalence rate of the group by 18.0%, 17.6% and 12.4% respectively one year, three years and six years after the implementation of the policy. For the high-income group of seniors, the two-week prevalence rate was reduced by 14.0% after the adjustment of the NCMS, and then no longer significant. However, as a result of the implementation of the policy, the rate of self-rated good health of the elderly in this group increased by 16.8% and 14.5% respectively three years and six years after the implementation of the project. Conclusion (1) After the adjustment of the NCMS, the two-week prevalence of the elderly in the intervention county decreased, and the policy effect was rapid and sustained. (2) The adjustment of the NCMS has no significant effect on reducing the prevalence of chronic diseases among the elderly in intervention counties. (3) The adjustment of the NCMS improved the self-rated health of the elderly in the intervention county, but the improvement effect gradually appeared after three years of intervention, reflecting the lagging effect of the policy adjustment on subjective health. (4) For the elderly with different income levels, the health performance of the NCMS is mainly reflected in the middle-low income, middle income and high income groups, and is not reflected in the low-income group and the middle-income group. KEYWORDS New Rural Cooperatives Medical Scheme, Rural elderly, Health performance宁夏医科大学硕士学位报告 目录 VI 目 录 前言.............................................................................................................................................1 1. 研究背景及意义.............................................................................................................1 2. 研究目的.........................................................................................................................2 3. 研究内容.........................................................................................................................3 材料与方法.................................................................................................................................4 1. 资料来源.........................................................................................................................4 2.干预组与对照组的政策差异...........................................................................................4 3. 变量的选取.....................................................................................................................4 4. 研究方案.........................................................................................................................6 4.1 抽样方法................................................................................................................6 4.2 研究对象................................................................................................................6 4.3 调查内容................................................................................................................6 4.4 质量控制................................................................................................................6 4.5 新农合健康绩效的评估方法.................................................................................7 4.6 技术路线..............................................................................................................11 4.7 创新之处..............................................................................................................11 结果...........................................................................................................................................12 1. 人口学特征描述...........................................................................................................12 2. 老年人健康状况描述...................................................................................................13 3. 倾向得分匹配（PSM）...............................................................................................13 4. 新农合方案调整对老年人健康绩效的影响...............................................................14 5. 新农合方案调整对不同收入老年人健康绩效的影响...............................................16 6. 边际效应.......................................................................................................................24宁夏医科大学硕士学位报告 目录 VII 讨论...........................................................................................................................................27 1. 样本县老年人的健康状况...........................................................................................27 2. 新农合方案调整对项目县老年人健康绩效的影响...................................................27 3. 新农合方案调整对不同收入组老年人健康绩效的影响...........................................29 结论...........................................................................................................................................32 建议...........................................................................................................................................33 致谢...........................................................................................................................................46 攻读学位期间发表的学术报告目录.......................................................................................47 个人简介...................................................................................................................................48 开题、中期及学位报告答辩委员组成...................................................................................49宁夏医科大学硕士学位报告 前言 1 前言 1. 研究背景及意义 随着社会的发展，人口老龄化问题逐渐演变为全世界范围内普遍存在的问题，也是 中国目前所面临的重要社会问题之一。我国于 2000 年便己经进入了老龄化社会，国家 统计局发布的统计数据显示 [1] ，老年人口的数量和比重在不断增加，至 2017 年底，我国 60 周岁及以上人口为 2.4090 亿人，占总人口的 17.3%，其中 65 周岁及以上人口达 1.5831 亿人，占总人口的 11.4%，预计到 2025 年，60 及以上老年人将达到 3.0 亿，我国将成为 超老年型国家。于此同时，更值得关注的是，我国城乡人口老龄化倒置严重，相对于城 市而言，我国农村的人口老龄化问题更为突出，由于居民平均寿命延长、出生率降低、 大量的青壮年劳动力外流等原因 [2] 致使老年人口相对增长，导致农村老年人口总数、老 龄化程度及速度均远高于城市 [3] 。农村老年人由于其生活水平相对较低，社会支持比较 薄弱，加之经济收入低，疾病的经济负担也重，其健康状况更易受到威胁。我国“十三 五”规划的主要目标之一是全面建成小康社会，目的在于提高人民的生活质量。而国民 的健康状况不仅是促进经济增长和可持续发展的关键，更是衡量人民生命质量和生活质 量的重要指标。随着老年人口比例的不断增加，势必会降低全民的健康水平，进而影响 整个社会的发展。对于农村老年人而言，其健康状况除了受经济收入、生活方式、文化 程度等方面的影响 [4] 以外，更多的则依赖于医疗保险制度和医疗服务质量，因此，新型 农村合作医疗制度成为农村老年人获得医疗保障的重要途径。 新型农村合作医疗（简称“新农合”）是针对农村居民出台的以大病统筹为主的农 民医疗互助共济制度，于 2002 年 10 月被明确提出，2003 年开始试点。2005 年，联合 国发布署发布的《人类发展报告》中指出，“中国的医疗体制并未帮助到最需要帮助的 群体，特别是农民”，即中国的医疗体制改革并不成功，因此，2009 年以后，新一轮的 医改再次启动。深化医改以来，河南、湖南、宁夏等地探索了不同的支付模式，宁夏与 2009 年在海原、盐池两县实施了“创新支付制度，提高卫生效益”的医改项目，实施门宁夏医科大学硕士学位报告 前言 2 诊、住院经费包干预付制，目的在于减轻参合农民的疾病经济负担，改善其健康状况。 政策实施前，新农合门诊是家庭账户，2010 年项目开始试行门诊统筹，对需方按不同级 别医院的阶梯状设置报销比例，对供方实行经费测算，进行门诊、住院经费包干预付。 并设立相关的激励机制，以引导医疗服务下沉，提高医务人员的技术水平，从而提供更 满足居民需求的医疗服务，进而减轻农民的疾病经济负担，改善其健康状况。在人口老 龄化背景的冲击之下，新农合政策的改革是否给老年人带来了医疗保障，是否有助于农 村老年人口健康状况的改善，是否有助于促进健康老龄化，其健康绩效到底如何，是我 们重点关注的问题。本文正是在该项目的基础之上，将两个实施支付制度改革的项目县 （海原县和盐池县）作为“干预组”，将两个未实施支付制度改革的对照县（西吉县和 彭阳县）作为“对照组”，运用卫生经济学的方法来探讨宁夏支付制度改革对项目县老 年人健康绩效的影响，分析新农合具体实施方案的调整是否促进了老年人的健康及其对 不同收入老年人健康状况的影响大小，进而评估支付政策的调整所带来的健康效益，以 期为进一步的政策调整和完善提供理论依据。本文将老年人的健康绩效定义为新农合政 策调整对提高老年人健康水平的作用 [5] ，通过评估新农合政策调整对两周患病率、慢性 病患病率和自评健康三个指标的影响大小来反映其健康绩效。 2. 研究目的 利用 2009-2015 年宁夏“创新支付制度，提高卫生效益”医改项目的调查数据，从 总体水平和不同收入谁水平分析新农合政策调整对老年人健康状况的影响，评价项目县 支付制度改革的健康绩效，为相关部门完善医保制度，促进宁夏统筹城乡医疗保障制度 健康持续发展提供参考依据。具体目标如下： （1）运用四次调查的数据，分别描述干预组和对照组老年人的健康现状； （2）分析新农合政策