| [Purpose]Critical illness medical assistance system with critical illness insurance system connecting closely is significant to alleviate the problem of poverty caused by illness,which is urgently to be solved.Currently,critical illness medical assistance system and critical illness insurance system just run.With little research,how to closely connect the two systems is still not clear and fully-fledged.Based on Synergy Theory,this study took empirical research on connection critical illness medical assistance system with critical illness insurance system,and put forward reasonable advices on perfecting it,in order to provide theoretical and practical reference for solving the problem of poverty caused by illness and promoting the health poverty alleviation project.[Methods]Drawing on ideas and methods of Synergy Theory,this study constructed logical framework of connection of the two systems,analyzed influencing elements deeply,evaluated reality and expectation gap,and identified opportunities for synergy.Literature review was used to study the domestic and international literatures on critical illness medical assistance,critical illness insurance and their connection.Via institution investigation,this study collected policy and claim database of basic healthcare insurance,critical illness insurance,basic medical assistance,critical illness medical assistance in 2015.Universal health coverage conceptual framework(UHC),descriptive statistical analysis and comparative analysis were used to analyze the connection effect.Through the interviews with key figures,this study found the views and advices of stakeholders on the connection of two systems.[Results]Firstly,the connection critical illness medical assistance system with critical illness insurance system has the synergistic characteristics of continuous development,and mutual adaptation.The synergy mechanism is that parameters dominate the behavior of critical illness medical assistance and critical illness insurance subsystems.Under the action of matter,energy and information,to improve reimbursement effect as goal,the subsystems change gradually,and connect closely in final.critical illness healthcare system gets order in time,space and function.Secondly,as to the system design,this study described from three aspects: population coverage,service coverage and cost coverage.It was found that there are different medical assistance modes in three areas.Critical illness medical assistance implemented by cost standard in place A,connecting with critical illness insurance,while by disease category standard in place B and C,connecting with NCMS major medical insurance.The medical assistance expanded to the poverty due to illness,but the standard is too simple or too high.Critical illness medical assistance in place B and C covered little in clinic,which also covered little by critical illness insurance.Patients with serious illness had high non-reimbursable expenses rate.Critical illness medical assistance in place A was not covered expenses out of medical insure catalogues.Poor people in place C were not reimbursed deductible of critical illness insurance by medical assistance,so that they are hard to utilize critical illness insurance.The two systems lack of coordination in function.Thirdly,as to the settlement connection,serious illness patients were compensated from basic medical insurance,critical illness insurance to medical assistance.Critical illness insurance was cumulative annual calculated,while critical illness medical assistance was calculated in sequence.The amount of medical assistance was calculated only according to the cost that time in some areas,thus medical assistance happens before critical illness insurance,then leading to the fund pressure increase.Settlement in treatment of Critical illness medical assistance covered the highest level in medical institutions and persons of place A,place B and C relatively low.In place C,settlement window is divided,not fully coordinated in space.Three areas medical assistance payments handed out after treatment all took long time.Fourthly,this study analyzes the elements from material flow,energy flow and information flow.Critical illness medical assistance capital took from the medical assistance funds.Medical assistance funds and medical insurance funds use independently in place A and C.The two funds in place B are relevant.Department of human resources and social security and department of civil affairs in place A and place C had high degree of coordination,resulting in wide medical coverage.Patients know little to critical illness medical assistance and critical illness medical insurance.Fifthly,as to the connection effect,The highest medical assistance coverage rate(65.93%)was in place A and the lowest(10.64%)in place C.The proportion of people in poverty caused by disease in place C is lower than place A and place B.After medical assistance reimbursement,the reimbursement level for critical illness medical assistance objects increased by 11,13,23 percentage points,but the OOP is still high.After critical illness medical assistance,OOP reduce substantially,but still up to 155 thousand Yuan.Some objects were not satisfied with the cumbersome procedure of a critical illness medical assistance application and long time waiting for medical assistance capital.Sixthly,based on its medical insurance,each country connects medical assistance with medical insurance,covering persons cannot covered by medical insurance.Most countries take family income and assets as standard,reimburse outpatient services,not limit diseases and take a number of measures to control medical costs,in order to reduce the burden of compensation.[Conclusions]Firstly,the connection critical illness medical assistance with critical illness insurance has gap in objects confirm,outpatient costs,the expenses out of medical insure catalogues,deductible and cap lines exist gap.It is advised to widen reimbursement,reduce collaboration space and narrow the gap between the two systems.Secondly,medical assistance further reduces burden,but the high cost of medical treatment and the absence of medical insurance in the dominant position limits the reimbursement effect.It is advised to strengthen the supervision,control medical expenses,strengthen the function of medical insurance and raise public awareness about of the critical illness insurance policy.Thirdly,settlement connection does not reach the time,space and function order.Critical illness medical assistance and critical illness insurance information sharing is not good.Their different characteristics lead to medical assistance pre problem.It is advised to strengthen the mutual information sharing among medical assistance system,basic medical insurance and critical illness insurance,covering all designated medical institutions.And strengthen the control to the information of patients' OOP after the basic medical insurance reimbursing,remind the patients who achieve the standard attention,pay attention to previous medical insurance reimbursement,and deduct the overmuch money.Fourthly,the connection of government,the medical assistance sector and the health care sector directly affect the connection process and effect of the two systems and easily lead to loose connection about system design and settlement.It is advised to integrate government resources,strengthen cooperation between department of civil affairs and relevant departments,and strengthen supervision of where the health insurance sector weakly control.Fifthly,the difficult crowd and general residents lack understanding of critical illness medical assistance and critical illness insurance policy,affecting the health service utilization and leading to poverty due to illness.It is recommended that critical illness medical assistance and critical illness insurance propagate policy together,integrate promotional resources,reduce publicity costs,improve the breadth and efficiency of publicity and connect residents with institutions. |
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