原标题：医疗费用贵在哪儿？调研解惑医保外自费医疗费用比例

┃来源：中国医疗保险

随着全民医疗保险制度的不断完善，医保参保病人的看病负担得到了有效缓解。“看病贵”问题更多地表现为不能为各种医疗保险所覆盖的医疗服务、技术与药品等相关直接自付费用。

本研究调查了上海城镇职工参保病人在各级医院住院的自付费用负担情况。研究发现，部分科室的医保住院病人存在自费比例偏高的情况，自费费用比较集中的领域是手术耗材、进口药物和专项检查等，但各级医疗机构对于参保病人自费比例的认识不足。

为此，在政策上应着力于构筑医院控制自费比例的内在动力机制；建立和完善医疗自费全过程监管机制，加强对重点医院、重点科室、重点领域的监管；适当扩大和完善保障范围，鼓励引导商业医疗保险发展。

上海基本医疗保险制度建设一直走在全国的前列，目前已基本实现了户籍人口的全覆盖。作为基本医疗保险制度体系中最重要的组成部分，上海市城镇职工基本医疗保险覆盖人群最广，保障范围和报销水平也最高。2017年，上海在职职工医保参保人员住院，超过起付线1500元以上部分，医保报销比例已经达到了85%，个人支付15%，最高支付限额达到了46万元。最高支付限额以上的医疗费还可以由地方附加基金支付80%。可以说，在现有制度可承受范围内，医保已经承担了参保人看病的大部分费用。

但是近年来，城镇职工医疗保险参保人员（以下简称参保人员）反映医疗负担重，特别是住院医疗负担重的呼声还是比较高，其原因在于医院尤其是三级医院的自费医疗项目日益增多。国际经验表明，医疗保险的保障水平以费用报销比例衡量，一般在75％-80％之间较为适宜。既不能过低，过低则保不住“基本”，也不能过高，过高则冲击了“分担机制”，容易形成福利依赖，造成医疗资源的巨大浪费，甚至冲垮医疗保障制度。

为了全面准确了解参保人员的医疗自费负担情况，进一步完善基本医疗保障制度，为了全面准确地摸清当前各级医疗机构和科室医保住院病人的自费医疗费用的比例，了解影响原因，本研究会同各区县医保中心、各三甲医院医保办公室共同开展了上海参保人员住院医疗费用自费比例的调研。

医保住院病人自费情况的调研

1、调研背景

理论上自费比例的水平应该与当前社会经济发展水平和公共资金的承担能力相适应。但自费医疗费用占比究竟该降到何种程度，国内外并无权威标准或参考，其原因：一是绝对科学、客观为基础的自费比例是不存在的。二是确定一个能让大多数医疗机构接受并自觉执行的自费比例是困难的。三是疾病或健康问题是复杂而多样的。综上，制定合理的自费比例存在多方面的限制和困难，但获取相对合理的控制指标并非不可能，关键是要让医疗机构自我认识达到统一，并有可操作性。

2、调研方法

本次调研采用“自我定位、同行评议和综合平衡”的方法来实施调查（自我定位是指让医院及科室客观如实填报当前住院病人的自费比例、理想(合理)的自费比例以及可以实现的自费比例。同行评议是指各医院或科室在完成自我定位的基础上，确定同一级别层次机构的合理自费比例及可实现自费比例等信息。综合平衡则是指最终控制比例的确定是综合医院提供信息的基础所确立的分类指导自费比例）。通过普查和抽样调查相结合的方法。本次调研主要由医疗机构及科室分别如实填报当前住院病人的自费比例、理想合理的自费比例和可以实现的自费比例，通过加权平均得出了由医院自填的自费比例，其次通过医院各科室自填比例加总计算后得出了该医院各科室加总自费比例。

3、样本情况

本次研究共调查了265家医疗机构，其中一级医疗机构110家，占调查医院总数的41.5%，二级医疗机构125家，占调查医院总数的47.2%，三级医疗机构30家，占调查医院总数的11.3%。

在调查的二、三级医疗机构中专科医院共63家，占比40.6%。其中，二级专科医院共计51家，占二级医疗机构总数的40.8%；三级专科医院共计12家，占三级医疗机构总数的40.0%。

各级医疗机构医保住院病人自费情况分析

1、医保住院病人的费用负担及自费比例

从总体来看，被调查的医疗机构年住院医疗总费用平均为10794.1万元，其中，各个医院城镇职工医保参保人员住院个人负担费用(包括分类自负、自负以及医保范围外的自费费用总和，下同)平均为1430.3万元，自费费用(医保范围外的费用，下同)为720.7万元。通过对医院自填自费比例的数据处理，将各医院发生的住院自费费用作为权数对住院自费比例进行加权平均后得出机构调查的城镇职工保险住院病人自费比例平均为18.68%。

这里需要说明的是：各家医院的自费费用水平不一，如果只是简单的对自费比例进行平均会放大某些规模很小的医院的自费比例的影响，所以在本研究中如不特别指出，医疗机构的平均自费比例均为以自费费用水平为权数的加权平均。根据各家医院的科室自费比例情况进行加总得出医院调整自费比例，加权后上海市自费比例平均为22.28%。

本研究重点关注三级医院的自费比例。三级医疗机构年住院医疗总费用平均为57912.99万元，其中，各个医院城镇职工保险参保人员住院个人负担费用平均为7654.31万元，自费费用为3786.15万元，平均自费比例为19.23%。根据各家三级医院的科室自费比例情况进行加总得出三级医疗机构调整自费比例平均为26.10%。

其中，三级综合医院职工保险参保人员住院个人负担费用平均为9661.33万元，自费费用为4998.96万元，平均自费比例为17.65%。根据各家综合医院的科室自费比例情况进行加总得出三级综合医疗机构调整自费比例平均为24.81%。

三级专科医院职工保险参保人员住院个人负担费用平均为4370.08万元，自费费用为1966.93万元，平均自费比例为25.80%。根据各家专科医院的科室自费比例情况进行加总得出三级专科医疗机构调整自费比例平均为34.01%（见表1）。

2、自费比例的科室分布情况

本研究将每家三级医疗机构各个科室填报的自费费用水平和自费比例按照科室类别进行汇总，筛选出现频数>5、频率>1%的科室按照不同科室平均自费费用水平由大到小排序后自左向右排列，按照科室平均自费比例由低到高自下向上排列得到图1。

其中，自费比例最高的前5位科室依次是骨科(38.45 %)、肝胆外科(35.63%)、肿瘤科(34.68%)、伤科(31.50%)、肛肠科(29.46%)。按照自费费用水平经过加权得出以上三级医院的科室的平均自费比例为25.69%，超过平均比例的科室有骨科、肝胆外科、肿瘤科、伤科、肛肠科、妇产科和胸外科。

根据对公立医院开展的问卷调查显示，各医院认为自费比例高的科室总体可归为三大类：第一类是以骨科和眼科为代表的外科；第二类是以血液科、肿瘤科为代表的重症科室；第三类是以老年科为代表的住院或治疗周期较长的科室(见表2)。

研究发现与政策建议

1、加强对重点科室和领域的重点监控

研究发现，以下领域中自费比例较高：

第一，手术耗材。骨科、胸外科、眼科等科室有较高的手术需求，对于一次性自费器械、耗材使用较多。

第二，进口药物。由于病种的复杂性和特殊性，如胆道科、肿瘤科、血液科病情复杂，往往采用进口药物治疗，如内分泌科的胰岛素注射针头、结直肠外科、神经内科等辅助治疗药品。这些耗材来源往往为进口，本身价格昂贵，属于高值耗材，并且医保报销比例较少或未纳入医保。

第三，检查项目。心内科、耳鼻咽喉、泌尿外科等科室诊断需要大量检查，如心内科的核磁共振、泌尿科激光碎石检查，耳鼻喉科大型设备检查也较多（见表2）。

因此，自费比较高的科室中，对于一次性器械等手术耗材、进口药物的使用以及自费项目的使用较多，在未来需要重点监控，进一步控制耗材和药物的使用，同时规范自费药品、耗材、项目的使用。

2、提高各级医院对医保病人自费比例的认知

调查显示，各家医疗机构对于城保住院病人在自家医疗机构内住院所发生的自费费用及其自费比例的认识基本一致，大部分都认为自身的自费比例适中或者偏低，只有极少的医疗机构认为自费水平是偏高的。由此可见，在医院实际的自费费用控制上仍然存在一定的接受难度，缺乏自身对自费比例控制的动力。

就一级医疗机构而言，没有一家医院认为自身的水平偏高，54%的医疗机构(共计60家)认为自费比例水平偏低，另外有32%的医疗机构(共计36家)认为当前的比例适中，还有15家机构没有作答。就二级医疗机构而言，只有2%的二级医疗机构(共2家）认为自身的水平偏高。只有1家三级医疗机构认为当前自身住院病人自费比例水平偏高，三级医疗机构中认为当前比例适中的机构占大多数，为68%（见表3）。

从政策角度来看，“增加过度治疗的机会成本,当边际成本超过边际收益时定点机构才会加强自律,规范治疗。引导就医流向可以降低来自参保人行为导致的费用增长。医保管理者在控制次均费用增长问题上责任重大，并大有作为。”

3、建立医院控制住院自费的内在机制

研究发现，各级医院对于参保病人自费比例的控制有着共识，也有着分歧。首先，在承认问题普遍存在的同时，认为自身的自费比例不高，自费高的是其他医院；其次，在降低自费比例的方法上大多数医院希望通过外界政策的完善予以实现，希望通过扩大医保目录、提高医保支付额度和报销比例等外部环境改变自费比例较高的现状，而缺乏内在的动力机制。

因此，“转变发展方式，实现可持续，不仅是指经济建设以及经济与社会的协调发展,而且包括社会建设的各个领域和各个方面。其中，医疗保障转变发展方式尤为必要和迫切。”政策应着力于构筑医院控制自费比例的内在动力机制，向各个医院下达可行的自费比例控制目标，引导医院减少自费费用的发生，降低自费比例水平。同时在医院内部不应简单地将这一指标按比例分摊到科室，而应根据各科室的实际情况和同类水平进行调整。

4、建立和完善医疗自费全过程监管

首先规范临床使用自费项目的流程监管，建立完整、规范的诊疗记录和临床路径，将自费药、自费项目的使用纳入医院HIS系统，对自费的发生做到全程有迹可寻。

其次，要充分落实患者的知情同意权，在对自费药物和项目的使用方面，需要充分向患者说明解释，征得患者及家属同意并签字。

再次，建立自费使用后备案机制。自费项目、自费药品使用后要统一在医保备案，方便监管与查询。

最后，加大违规监管处罚力度，引入社会群众舆论监督机制，加强重点医院、重点科室、重点领域的监管。

5、适当扩大和完善保障范围，鼓励引导商业医疗保险发展

针对参保病人住院自费负担的实际情况，对调研中发现参保人员需求较大的、疗效确切且没有良好替代品的部分药品或医用材料，可逐步纳入医保范围，同时也可通过适当拉开报销比例的方式，鼓励参保人员使用物美价廉的国产产品，降低医疗费用水平。

此外，基本医疗保障是动态的、发展的，随着医疗技术、社会经济发展水平的提高以及居民医疗需求水平的提高而不断提高。由于现阶段上海商业医疗保险尚不完善，所以社会基本医疗保险制度承担了满足居民医疗需求的全部负荷。因此，建议加强对商业保险的研究，大力推进商业医疗保险的发展以补充社会医疗保险。

作者：上海行政学院贺小林

详见《中国医疗保险》杂志2017年第6期

原标题：上海职工医保参保人员住院负担分析与政策思考

https://www.ixueshu.com/document/ab5a1cdb89035d7d9e908a3c0d3d464d.html 1.第三方支付平台提供预约挂号，拓宽了原有的预约渠道，手机预约挂号更便捷，提升了预约就医率 2.在线缴费查报告减少排队时间，等待时间，优化了就医流程，改善了就医体验 3.自助化、智能化手机就诊，大大减少了人工窗口，降低了医院运营成本 4.优化就医流程，提升患者满意度

医保移动支付并没有探讨使用了医保移动支付对医院收入的影响增多或者减少

The CareCredit medical card has been fined by regulators for deceptive marketing, but it gets high marks from health care groups. Over 100 professional groups -- including such well-known ones as the American Dental Association -- endorse the card.

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But there's a big asterisk on those endorsements: CareCredit pays for most of them.

In a regulatory filing Thursday, the credit card company revealed that it pays dozens of professional societies to convince their members to pitch the high-interest credit cards to patients.

CareCredit had relationships with 107 professional associations and other groups as of Dec. 31, 2013. "Of these relationships, 63 were paid endorsements linked to member enrollment in the relevant program," according to a filing with the U.S. Securities and Exchange Commission.

Professional associations contacted by CreditCards.com defended paid endorsements, while legal experts said the practice is problematic, especially in the health care environment.

"I think it's troubling because medical professionals tend to build up trust," said Jeff Sovern, law professor at St. John's University. Patients might trust their provider to steer them into the best deal, without knowing that a paid endorsement influenced the provider's choice.

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"If this leads to poor decision making by the patient, I think there's a real risk," said Jim Hawkins, law professor at the University of Houston.

Legal protections bypassed

Protections in the U.S. Truth in Lending Act are designed to help consumers compare different financing offers. Influencing a care provider's recommendation via a paid endorsement from a professional association can help cards avoid the scrutiny of comparison shopping, Sovern said.

CareCredit has been cited for faulty marketing practices by the New York Attorney General's office and by the U.S. Consumer Financial Protection Bureau. Patients frequently misunderstand the cards' delayed interest terms and wind up owing hefty surprise charges, the regulators said.

In a December order, the CFPB barred CareCredit from paying "kickbacks, rebates, compensation or in-kind services" to medical offices in return for signing patients up for its cards. However, it did not prohibit the company from paying professional societies in return for enrolling medical offices to pitch the card to patients.

Other card issuers, including Wells Fargo and Citibank, offer medical care credit cards that have not been cited by regulators for their marketing practices.

CareCredit owner GE Capital refused to comment beyond the information in the regulatory filing.

The endorsements from professional associations are important to the medical card's business, the filing states. CareCredit attracts new health care providers "largely by leveraging our endorsement from professional associations and health care consultants," according to the filing. How much it paid for the endorsements was not revealed.

At Dec. 31 2013, CareCredit had 149,000 health care provider offices that agree to provide its cards. At the consumer level, it had 4.4 million active accounts with total balances of $6.5 billion, according to the filing, with an average debt per customer of $6,222. CareCredit cards carry rates above 25 percent, which may be deferred for six months or longer.

GE Capital plans to spin off its consumer financial business, including store credit cards and CareCredit, into a separate entity named Synchrony Financial. Uninsured health services including dental work, hearing aids and veterinary care for pets are among the most common uses for medical cards such as CareCredit.

Endorsements and the public

While CareCredit uses paid endorsements to market its card to health service providers, it does not use the endorsements in marketing materials directed at patients, according to a legal filing that settled New York State's investigation into the card in 2013.

But neither are the professional endorsements a secret from the public. On its website, the American Dental Association carried a news announcement dated Jan. 10, 2012 calling CareCredit the only health care financing company endorsed by ADA Business Resources, a unit of the ADA. An ADA representative would not discuss the professional group's business arrangement with CareCredit.

The American Animal Hospital Association, another CareCredit endorser, said it carefully selects the companies it endorses in return for royalties, and monitors their performance.

"AAHA is very particular about our Preferred Provider Program," communications manager Kate Spencer said in an email response to questions. "We have a very limited number of these relationships and we monitor the programs on an ongoing basis in an effort to ensure our programs are the best option for our members."

Even when an endorsed product is selected carefully, any payment for the endorsement should be disclosed -- to patients as well as to service providers, one health care expert said.

"Given the unique nature of medical debt, it is crucial that due diligence be done by any health-related association offering an endorsement of a medical credit card," said Mark Rukavina, founder of a health care business consultant Community Health Advisors and member of a medical debt and price transparency task force convened by the Healthcare Financial Management Association.

"Transparency is vital," he said in an email response to questions, "and it is important for providers and patients, alike, to know if the association was paid for its endorsement."

Paid endorsements have come under fire in other business areas, and calls for disclosure of the deals is increasing. Under the Credit CARD Act, colleges were required to disclose their marketing arrangements with credit cards, leading to fewer such agreements and a reduction in money paid to colleges under the agreements. In December 2013, the Government Accountability Office issued a report urging colleges to reveal marketing deals for debit cards and prepaid cards.

In the medical industry, drug companies and medical device makers have cut payments to health professionals for promotional speeches, as disclosure requirements -- part of the 2010 federal Affordable Care Act -- approach their effective date.

Debt collection violation disclosed

Synchrony Financial's filing also disclosed that it discovered, through an audit of its debt collection operations in 2012, that some Spanish-speaking customers and customers in Puerto Rico were excluded from settlement offers and statement credits that were offered to others. The lapse, a possible violation of the Equal Credit Opportunity Act, was reported to the CFPB and is the subject of a civil investigation by the U.S. Justice Department, according to the filing. The resolution could involve payments to customers "in addition to what we have voluntarily undertaken," as well as fines imposed by regulators. The card issuer also said it is in discussions with the CFPB over the marketing of its debt cancelation products, which have been the target of fines levied on other card companies.

GE Capital is the largest store-card issuer in the U.S. and one of the largest credit card companies, with 62 million active accounts and $94 billion in purchase volume in 2013.

See related: Medical credit cards: Treatment today, payment headaches tomorrow

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Health & Wellness Rebates

MB F&F

Rebates in Singapore & Malaysia

Citi SMRT Card

EZ-Link compatible with no minimum spend

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Big Hospital BillsUnlimited Cards, HSBC Advance
Bill-Pay in 0% InstalmentsOCBC Cashflo, SC SingPost Spree
No-Fee Cards for Medical BillsCIMB Plat MC, HSBC Rev
Miles for Hospital Bill-PaySC Visa Infinite
Health & Wellness RebatesMB F&F, Citi SMRT & more

Best Credit Cards for Paying Big Hospital Bills

Depending on the procedure and hospital, medical bills can be quite large. The following cards allow consumers to continue earning rewards beyond the caps of typical cashback cards.

wanghaisheng / finance-option-for-patient-and-hospital

ref #1

Best Credit Cards for Paying Big Hospital Bills

Best Unlimited Cashback Card + EZ-Link: Standard Chartered Unlimited Cashback Card

Best Unlimited Cashback Card with Amex Benefits: American Express True Cashback Card

Best Rebate Card for Paying Large Hospital Bills: HSBC Advance Card

Best Cards for Paying Hospital Bills in 0% Interest Instalments

Best for Earning Rebates on Bill Pay over Instalments: OCBC Cashflo Card

Best Cashback Card for Online & Overseas Payments: Standard Chartered SingPost Spree Card

Best No-Fee Credit Cards for Paying Hospital & Medical Bills

Best Cashback Card for Health, Travel & Transport: CIMB Platinum MasterCard

Best Miles Card for Online Bill-Pay: HSBC Revolution Card

Best Card for Earning Miles by Paying Hospital Bills: Standard Chartered Visa Infinite Card

Best Credit Cards for Earning Health & Wellness Rebates

Best Card for Wellness Rebates in Singapore & Malaysia: Maybank Family & Friends MasterCard

Best Rebate Card for Young Professionals: Citi SMRT Card

Best Card for Rebates on Essentials: POSB Everyday Card

Summary of Best Credit Cards for Paying Hospital Bills 2019

Compare the Best Credit Cards for Hospital Expenses by Dollar Value

http://money.com/money/4814753/carecredit-medical-credit-cards/ What to Know About Medical Credit Cards Before Signing Up

What to Watch For

Is it Right for You?

Patient Financial Care Leader and Healthcare Credit Card Giant Team to Provide Patients More Options to Pay for Healthcare Expenses

说一说那些有医院挂号权益的信用卡

前言

本文中出场的信用卡

农业银行的白金卡

中信银行的大白金和顶级卡

广发卡：

兴业的悠悦健康白金卡

建行的大白金

结语