CAJ | 학술논문

目的：了解某市居民实际门诊和住院医疗的疾病类型、医保类型、医疗费用及费用支付方式现状，探讨基本医疗保障中存在的主要问题，并提出对策建议。方法将某市主城区公立医院分为一级医院、二级医院、三级医院三类，采用随机抽样方法，从三类医院中各抽取1家医院。2011年1—12月，从每月中随机抽取某1天，获取“门诊与出院患者及费用”等数据，分析现状和存在的问题。结果某市居民门诊平均总费用134.13元，其中自费117.39元，报销比例为12.48%。住院患者平均总费用4123.38元，其中自费2325.75元，报销比例为43.60%。药品费用占门诊医疗费用的比例为74.37%，占住院医疗费用的63.33%。三所公立医院按医院等级划分的门诊自费人次比例、门诊自费支付金额、门诊统筹支付金额、门诊药品费用、住院医保类型、住院医疗费用、住院医疗费用支付方面差异有统计学意义（P<0.05）；按疾病划分的门诊医保类型、门诊医疗费用、门诊医疗费用支付、住院费用支付、住院医疗费用方面差异有统计学意义（ P<0.05）；诊疗相同的门诊疾病、住院疾病在费用和支付方式上差异也有统计学意义（P<0.05）。结论居民基本医疗的负担仍较重，医疗费用中药品比重较高，医疗保险支付方式较单一。建议建立基本药物统一采购、供应制度，各级医院同步使用基本药物，降低基本医疗费用；建立完善、科学的基本医疗保险支付体系，充分发挥医保资金的保障效率；建立基本医疗监管机制，防止资金滥用。
목적：료해모시거민실제문진화주원의료적질병류형、의보류형、의료비용급비용지부방식현상，탐토기본의료보장중존재적주요문제，병제출대책건의。방법장모시주성구공립의원분위일급의원、이급의원、삼급의원삼류，채용수궤추양방법，종삼류의원중각추취1가의원。2011년1—12월，종매월중수궤추취모1천，획취“문진여출원환자급비용”등수거，분석현상화존재적문제。결과모시거민문진평균총비용134.13원，기중자비117.39원，보소비례위12.48%。주원환자평균총비용4123.38원，기중자비2325.75원，보소비례위43.60%。약품비용점문진의료비용적비례위74.37%，점주원의료비용적63.33%。삼소공립의원안의원등급화분적문진자비인차비례、문진자비지부금액、문진통주지부금액、문진약품비용、주원의보류형、주원의료비용、주원의료비용지부방면차이유통계학의의（P<0.05）；안질병화분적문진의보류형、문진의료비용、문진의료비용지부、주원비용지부、주원의료비용방면차이유통계학의의（ P<0.05）；진료상동적문진질병、주원질병재비용화지부방식상차이야유통계학의의（P<0.05）。결론거민기본의료적부담잉교중，의료비용중약품비중교고，의료보험지부방식교단일。건의건립기본약물통일채구、공응제도，각급의원동보사용기본약물，강저기본의료비용；건립완선、과학적기본의료보험지부체계，충분발휘의보자금적보장효솔；건립기본의료감관궤제，방지자금람용。
Objective To learn the types of diseases and the types of medical insurances as well as the medical expen-ses and payment status quo of outpatients and inpatients in a city,explore the existing problems of basic medical security and put forward countermeasures and suggestions. Methods The municipal public hospitals were divided into three levels:First,Second and Third. A random sampling method was used to select one hospital from every level and then by the same method a random date was selected from each month of 2011. The data about the outpatients,inpatients and medical expenses on that day of each month were obtained respectively and analyzed in order to find the existing problems. Results The mean total cost per outpatient was ￥ 134. 13. Their private expense was ￥ 117. 39 and the reimbursement ratio was 12. 48%. The average total cost of hospitalized patients was ￥ 4 123. 38. The private expense was ￥ 2 325. 75 and the reimbursement ratio was 43. 60%. Pharmaceutical costs ac-counts for 74. 37% of outpatient expenditures and 63. 33% of inpatient expenditures. The differences in the proportion of self-paid patients,outpatient medical expenses,the amount of outpatient overall planning payment,outpatient medicine expenses, the types of hospitalization insurance, hospitalization medical expenses, hospitalization medical expenses payment among the three levels of hospitals were statistically significant(P<0. 05);the types of outpatient medical insurance,outpatient medical expenses,outpatient medical expenses payment,hospitalization expenses,hospitalization medical expenses payment had obvious differences in terms of different diseases(P<0. 05);the differences in expenses and payment mode between outpatient diseases and inpatient diseases with the same diagnosis were also statistically significant(P<0. 05). Conclusion Residents basic medi-cal burden is still heavier and the proportion of medicine expenses is also higher and the medical insurance payment mode is rela-tively single. It is suggested that:basic drugs unified purchase and supply system be built,basic drugs be used synchronously in all levels of hospitals and basic medical expenses be reduced;a perfect and scientific payment mode system be established to guarantee the efficiency of medical insurance funds safeguard in full play;a basic medical supervision mechanism be built to pre-vent the misuse of funds.