【作者】 许红华；

【导师】 魏晓平；

【作者基本信息】 中国矿业大学 ， 工程管理， 2011， 博士

【摘要】 城镇职工基本医疗保险制度是我国社会医疗保障体系中重要的组成部分,该制度可持续发展的关键是医疗保险基金的平稳高效运行。我国于1999年开始实施城镇职工基本医疗保险制度,历经13年,虽然总体上全国医保基金帐户呈现结余现象,但是不同人口结构、产业结构、经济发展水平的地区基金运行状况却大不相同,结余和亏空的现象参差不齐并且较为严重。紧密结合当地实际和医疗保险自身特点进行科学精确的基金收支测算是医保基金管理的首要工作,也是医保基金平稳高效运行的基本保证。因此,本文以城镇职工医保基金运行过程中的三个方面:基金筹集、费用支付、基金管理为切入点展开深入研究,试图在详细全面的理论研析之上,科学系统地测算与分析城镇职工医保基金运行过程中的各项关键指标,并对医保市场各方博弈行为进行建模分析,在此基础上探讨医保基金各个运行环节的管控策略,为医保基金的平稳和高效运行提供思路和方法的支持,为城镇职工基本医疗保险制度的完善与改革提供理论和实证参考。本文首先对医保制度的相关理论进行了梳理,并评述了国内外关于医保基金筹集、支付和运行的研究进展情况;回顾和分析了我国城镇职工基本医疗保险基金运行的历史与现状,实证分析提炼了我国城镇职工基本医疗保险基金收入与支出的影响因素。其次,以X市为例,运用ILO筹资模型结合核密度估计对其城镇职工医保基金的年度筹资比例进行了测算,运用灰色关联模型对基金的收支平衡状况进行了预测分析;结果显示,在经验风险储备金乘数0.131情况下,测算出的X市筹资比例为7.7%左右;在2012年之前X市的医疗保险基金的运行是平稳的,但是从2012年之后基金陆续出险,且基金在2016年后全部出险。第三,从医疗服务提供方的角度,运用时间序列法对我国城镇职工医保基金的支出进行了测算,并通过构建模型进行实证研究证实了医保市场供方诱导需求情况的存在。从医疗服务需求方的角度,运用微观模拟分析模型对X市的城镇职工医保基金的支出进行了模拟测算。结果显示,X市2010年至2014年5年间医保统筹基金执行70%的住院费用补偿比将比执行现行补偿比少支付大约合计11亿元,实行70%的住院费用补偿比更符合X市的实际。然后,对医-保-患三方主体两两之间的与医疗保险费用控制有关的行为进行了建模与分析,并以X市为例进行了实际数据的验证。结果表明,X市城镇职工医疗保险市场存在医疗保险欺诈行为,提高医疗保险基金的使用效率的关键因素是:加大对医疗机构违规收费的惩罚力度,同时增加医保机构的收益,降低其监督成本。最后,论文在以上数理研究与结论的基础上提出了一系列完善我国城镇职工基本医疗保险基金的管理策略。论文有图16幅,表70个,参考文献148篇。更多还原

【Abstract】 Urban employees’basic medical insurance system is an important part of the social medical security system in our country. The smooth efficient running of the medical insurance fund (MIF) is the key to the sustainable development of this system. Urban employees’basic medical insurance system has been put into effect in 1999 in China. After 13 years, although national MIF presents surplus, MIF’s operation of districts which have different population structure, industrial structure and economic development level are very different, both surplus and deficit are common and serious. Scientific accurate income and outcome calculation closely integrated with their own characteristics is the priority of MIF’s management and the fundamental guarantee of MIF’s smooth efficient operation. Therefore, this paper puts into deep research from three aspects of MIF’s operation -- fund raising, payment, fund management and control, and attempts to make an scientific accurate calculation and analysis for key indicators of the operation the urban employees’MIF, construct models and analyze the gaming behavior of the different subjects in the medical insurance market, and study the management and control strategies of each link if the MIF’s operation. All these above hope to provide thoughts and methods for how to keep Smooth efficient operation of the medical insurance fund and theoretical and empirical references for perfection and reform of the urban employees’basic medical insurance system.Firstly, this paper hackles the related theories on medical insurance system and elaborates the research progress at home and abroad on the financing, payment and operation of the medical insurance fund. After that, it reviews and summarizes the historical and present situation of the operation of urban employees’basic medical insurance fund in China. Then, it refines the factors through empirical analysis which influences the revenue and expenditure of the urban employees’basic medical insurance fund in China.Secondly, taking X city for example, we calculate the annual financing ratio of X city through using ILO Financing Model and Kernel Density Estimation. We also forecast and analyze the balance between income and outcome of the urban employees’basic medical insurance fund through using Grey Relational Analysis Method. Studies have shown that the calculated financing ratio is 7.7% if the experienced risk multiplier takes a value of 0.13. Under present medical insurance policies, the medical insurance fund is able to operate safely and stably before 2012. However, the fund would be start facing deficit successively at the different growth rate of salary (pension) after 2012, and would be involved in deficit completely after 2016. Thirdly, from aspect of medical service provider, we calculate the national outcome of the urban employees’basic medical insurance fund through using Time Series Method and confirm exist of the physician-induced demand through Empirical research based on constructed model. From aspect of medical service demander, we make a simulated estimation for outcome of the urban employees’basic medical insurance fund in X city through using Microanalysis Simulation Model. The results shows that within five years, compensating 70 percents of hospitalization costs will save about RMB 1.1 billion than present proportion and is a better choice for X city’s current situationThen, we construct game models between each two sides among hospitals, insurance institutions and patients. Through putting the data of medical insurance illegal cases in X city into the game model and taking an analysis, we found that it is a common phenomenon that the medical insurance fraud exists in X city. The key to improve efficiency of the urban employees’basic medical insurance fund is that increase punishment of the illegal fees and increase gains of insurance institutions, reduce its supervision costs.Finally, on the basis of theory and mathematical research, this paper has put forward a series of management strategy in perfecting the management of urban employees’basic medical insurance fund in our country. This paper has 15 graphs, 72 tables, 148 references.更多还原