论文标题：Impact of an innovative financing and payment model on tuberculosis patients’ financial burden: is tuberculosis care more affordable for the poor?

期刊：

作者：Wei-Xi Jiang, Qian Long, Henry Lucas, Di Dong, Jia-Ying Chen, Li Xiang, Qiang Li, Fei Huang, Hong Wang, Chris Elbers, Frank Cobelens and Sheng-Lan Tang

发表时间：2019/03/24

数字识别码：10.1186/s40249-019-0532-x

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每年的3月24日是世界防治结核病日，今年世界防治结核病日的主题是“时不我待”。世界卫生组织呼吁各国采取行动，扩大预防和治疗服务的获取，并积极推动加快结核病防治及确保医疗保健获取的工作。

在今年的世界防治结核病日，Infectious Diseases of Poverty 发表的文章以定量和定性相结合的方式，详细分析了以提高结核患者的医保报销比例，并实施按病种付费的支付方式为主要干预措施的新型筹资支付方式对普通结核患者，特别是对贫困患者经济负担的影响。

以下是关于这篇论文的详细介绍。

结核作为一种古老的传染性疾病，目前依然需要6-8个月的疗程才能治愈，而耐药结核的治疗时间更长。明升中国作为全球结核疾病负担最高的国家之一，结核防治服务已由疾病预防控制中心/结核病防治所统一负责公共卫生服务和临床治疗的模式，转向由以综合医院为主的定点医疗机构提供临床服务、基层乡镇卫生院/社区卫生服务中心负责患者转诊和管理、疾控中心负责疾病监测等公共卫生等工作的“三位一体”模式。在新的结核防治模式下，尽管明升中国有一线抗结核药物免费发放的政策，结核患者依然面临较重的经济负担。而且结核患者多为低收入群体，高额的治疗费用影响治疗依从性的情况并不罕见，给明升中国终止结核疫情、实现2030健康相关可持续发展目标带来严峻的挑战。

在减轻结核患者经济负担的研究领域，Infectious Diseases of Poverty 最近发表了一篇文章，以定量和定性相结合的方式，详细分析了以提高结核患者的医保报销比例、实施按病种付费的支付方式为主要干预措施的新型筹资支付方式对普通结核患者，特别是对贫困患者经济负担的影响。研究者在新筹资支付模型实施前后开展了面向普通结核患者的问卷调查以及针对患者和医务人员的定性访谈，发现新模型实施后患者人均自付医疗费用不减反增，而且最贫困的患者自付医疗费用和发生灾难性支出的概率增长的百分比显著高于最富裕的患者。

定性研究结果表明，尽管新模型指定了标准医疗服务包，医院依然会提供标准包外的服务，特别是对于有并发症、合并症的患者。患者临床服务包外的医疗服务利用增长，而这部分费用无法被新筹资支付模型覆盖，可能是导致自付费用和经济负担不减反增的原因。而医生的个人收入也与科室医疗收入挂钩，存在过度提供医疗服务的动机。

文章的结论指出，在当前医疗体系的大背景下，明升中国临床医生的收入普遍与科室医疗业务的收入相关。如果不能将所有医疗服务纳入新筹资支付制度覆盖的范畴，医生将始终有动机提供过度的医疗服务，使得患者的经济负担增加。此外费用控制的额策略也亟待开发和实施，以提升明升中国基本医疗卫生服务的有效覆盖。

摘要：

Background

In response to the high financial burden of health services facing tuberculosis (TB) patients in China, the China-Gates TB project, Phase II, has implemented a new financing and payment model as an important component of the overall project in three cities in eastern, central and western China. The model focuses on increasing the reimbursement rate for TB patients and reforming provider payment methods by replacing fee-for-service with a case-based payment approach. This study investigated changes in out-of-pocket (OOP) health expenditure and the financial burden on TB patients before and after the interventions, with a focus on potential differential impacts on patients from different income groups.

Methods

Three sample counties in each of the three prefectures: Zhenjiang, Yichang and Hanzhong were chosen as study sites. TB patients who started and completed treatment before, and during the intervention period, were randomly sampled and surveyed at the baseline in 2013 and final evaluation in 2015 respectively. OOP health expenditure and percentage of patients incurring catastrophic health expenditure (CHE) were calculated for different income groups. OLS regression and logit regression were conducted to explore the intervention’s impacts on patient OOP health expenditure and financial burden after adjusting for other covariates. Key-informant interviews and focus group discussions were conducted to understand the reasons for any observed changes.

Results

Data from 738 (baseline) and 735 (evaluation) patients were available for analysis. Patient mean OOP health expenditure increased from RMB 3576 to RMB 5791, and the percentage of patients incurring CHE also increased after intervention. The percentage increase in OOP health expenditure and the likelihood of incurring CHE were significantly lower for patients from the highest income group as compared to the lowest. Qualitative findings indicated that increased use of health services not covered by the standard package of the model was likely to have caused the increase in financial burden.

Conclusions

The implementation of the new financing and payment model did not protect patients, especially those from the lowest income group, from financial difficulty, due partly to their increased use of health service. More financial resources should be mobilized to increase financial protection, particularly for poor patients, while cost containment strategies need to be developed and effectively implemented to improve the effective coverage of essential healthcare in China.

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期刊介绍:

Infectious Diseases of Poverty(, 2.708 - 2-year Impact Factor, 3.126 - 5-year Impact Factor) is an open access, peer-reviewed journal publishing topic areas and methods that address essential public health questions relating to infectious diseases of poverty. These include various aspects of the biology of pathogens and vectors, diagnosis and detection, treatment and case management, epidemiology and modeling, zoonotic hosts and animal reservoirs, control strategies and implementation, new technologies and application. Transdisciplinary or multisectoral effects on health systems, ecohealth, environmental management, and innovative technology are also considered.

（来源：明升手机版(明升中国)）