【作者】 徐伟；

【导师】 顾海； 王怀明；

【作者基本信息】 南京农业大学 ， 农业经济管理， 2011， 博士

【摘要】 我国的医疗保障制度是在新中国成立后逐步建立和发展起来的。由于经济发展中城乡二元结构等的原因,我国的医疗保障制度是城乡分离的,各自有不同的特点和发展过程。在城镇,先后经历了劳保医疗、公费制度,城镇医疗保险改革和试点阶段,全国范围内城镇职工基本医疗保险制度的确立,以及多层次医疗保险体系的探索,随后城镇居民基本医疗保险制度的确立等阶段；在农村,伴随着合作医疗制度的兴衰,努力开展新型农村合作医疗制度的建设工作,进而对农村医疗保障制度多样化进行探索与完善。随着我国医疗保险制度的变迁到现阶段,我国已经步入全民医保的时代,覆盖全民医疗保险的三项基本医疗保险制度分别是城镇职工基本医疗保险制度、城镇居民基本医疗保险制度和新型农村合作医疗保险制度。随着社会经济发展和医疗保险制度覆盖范围的不断扩大,城乡分割的保险制度并存的弊端逐渐显现出来,多种医疗保险制度并存的格局不能很好地适应社会发展和群众保障需求,束缚或阻碍了医疗保障的发展进程。那么,这些弊端和束缚具体是由哪些因素造成的?从实现社会公平和提高公共管理效率出发,如何对现有的医疗保险制度和管理服务资源进行整合?政府提出的统筹这一改革思路,从经济管理的角度,在现阶段的江苏是否可行?如何制定城乡医保统筹的具体制度?本文以江苏基本医疗保障为特定的研究对象,通过文献、现场调查、焦点组等方式收集相关数据,在定量分析的基础上,借鉴国内外医保统筹的模式、路径和制度,运用相关经济学的知识,来分析江苏省基本医疗保障的现状,总结出其中存在的问题,并试图给出一个可行的“统筹城乡的江苏省基本医疗保障制度”的框架。全文分为八个部分,主要的研究内容和结论如下：研究内容一：江苏省现行基本医疗保障制度中存在的问题分析本文通过调研发现的江苏省现行基本医疗保障制度中存在的问题,通过卫生诊断树的方法,归纳到筹资、组织管理和支付补偿这几个方面进行系统的研究,得到以下的结论。现阶段江苏省农村社会结构发生了深刻的变迁,现行的江苏省三项基本医疗保险制度遵循城乡分制的设计理念,按照居民身份来确定参保险种,不适应江苏省不同收入人群对不同的医疗保险的需求,与社会发展的趋势相背离。目前江苏省三项医疗保险基本上都是以市、县一级统筹为主,统筹层次过低使得江苏各地区几乎每个市(县)的筹资标准都不同,导致了横向筹资的不公平。特别是苏南地区和苏中、苏北地区的筹资和财政补贴巨大差异导致现有卫生筹资政策对低收入人群的不利,低收入群体在个人缴费筹资方面的压力高于其他群体。同时筹资制度的不合理安排还使得部分地区医保基金运行存在较大风险。大部分地区实行医疗保障制度的管理机构分治,即城镇职工医保制度和城镇居民医保制度由劳动保障厅的医疗保险处管理,而新农合则是在卫生厅管理,而卫生厅与劳动保障厅是同等级单位,这就给三项基本医保制度的管理带来诸多不便,造成管理成本提高,管理效率降低,对群众享受公平的基本医疗保障造成阻碍。从补偿待遇水平上看,现行医保制度覆盖范围与保障对象相互交叉,各地各险种保障模式繁杂,各地财政水平的不同造成补偿力度差异较大,不能保障居民平等享受基本医疗服务,违背了医疗保障的公平原则,降低了居民参保的积极性。在这部分研究的基础上,本文提出有必要统筹城乡的基本医疗保障。研究内容二：统筹城乡的基本医疗保障与福利水平的提高本文通过一个理论模型说明实施统筹城乡的医疗保险可以带来三方面的福利改善。一方面是将新农合的基金管理职能从卫生部门中独立出来,可以较为有效的发挥第三方监管职能,通过支付方式的改进和谈判机制控制医生的诱导需求及道德风险,控制不必要的医疗消费,有效控制了医疗服务的价格和提高消费者的福利；第二个方面是统筹可以提高医疗保险的报销待遇,有效分担了参保人的一部分医疗负担；第三个方面是城乡医保管理机构的整合,有利于合理整合和有效利用人、财、物等管理资源,减少由于信息系统分立而带来的重复参保问题,减小医保工作难度,减少管理成本,这都将带来医保待遇的提升,提高参保人员的整体福利水平。在理论分析的基础上,本文通过江苏省实地调研,用实证的方式证明当筹资标准、封顶线一定时,城乡医保管理机构统一的地区,其保障水平比城乡医保管理机构分治的地区高8.13个百分点。理论和实证结果表明统筹后的基本医疗保障管可以减少资源的浪费,提高福利水平,统筹城乡的基本医保这一方案可以改善江苏现行医保制度运行过程中的部分问题。研究内容三：论证江苏省现阶段是否可以实施统筹城乡的基本医疗保障制度江苏省由于地域差异,整体经济发展差异较大,一般而言,江苏经济呈现南方好于北方的情况,传统按照江苏省经济发展状况将其分为苏北、苏中、苏南三个地区。虽然城乡医保统筹是一个可供选择的方案,但是是否能够在这样差距的经济不均等地域实施统筹,还有待进一步验证。我们选择了经济财政、城乡收入差距、资源配置的公平性和医保的转移接续这四个主要的因素来详细探讨江苏省城乡医保统筹所面临的障碍。从经济因素与医疗保障统筹的关系分析来看,在江苏省人均GDP处于较高平均水平时,江苏各地的经济发展水平的相对差距,不影响江苏在现阶段实施城乡统筹的医疗保障；江苏省城乡收入的差距和交错,要求建立一种打破身份界限的医疗保险制度,针对不同人群的经济负担能力和医保需求提供不同层次的保险。卫生服务资源配置是公平实施统筹医保的基础,在这一因素上,江苏走在了全国的前列,在更好的提高卫生资源配置公平性的情况下,江苏可以在全国率先实施城乡统筹的医疗保险制度。目前江苏省已经在进行异地就医的试点并将短期内在全省范围实现异地就医,这也为城乡医保统筹奠定奠定了制度和结算平台的基础。这些因素的分析表明江苏现阶段有条件实施统筹城乡的基本医疗保障制度。研究内容四：统筹城乡的基本医疗保障制度框架的设计医疗保障制度的设计主要涉及两方面的问题,即筹资方案和补偿方案,其设计原则应该遵循选择一种最少效率损失且最公平的组织形式,并且不致于造成医疗开支的恶性膨胀,又能切实解决参保居民医疗负担。通过仔细的测算,差异化医保合约组合的筹资标准和支付补偿标准如下：A类医保选择性合约的个人筹资标准定为350元(包含大病保险),相应的缴费基数总额定为1750元,相应的报销比率也应该提高到75%-80%,起付线定为400、600、1000元,封顶线为18万元；B类的报销比率提高到50%-55%,起付线定为300、500、1000元,封顶线为10万元,相应的筹资标准提高到400元,个人负担200元,剩余部分由政府补贴；C类的筹资标准中个人缴费60元,加上财政补贴200元,筹资总额为260元,报销比率也应提高到35%-40%,起付线定为300、450、1000元,封顶线为7万元。本文根据社会群体经济收入水平和对医疗保险需求倾向,尝试建立基本医疗保障管理机构统一、多层次、自由选择的统筹城乡的基本医疗保障制度。更多还原

【Abstract】 The Chinese medical care security system has been formed and developed since the foundation of New China. The system has been short of unity between urban and rural areas due to such causes as disparity between urban and rural economic development, which shows different features and development process. The urban areas have witnessed various medical insurance systems such as medical care of labor protection, public medical care, reform and pilot of medical insurance of urban areas, nationwide basic medical insurance for urban employees, basic medical insurance for urban for urban residents. Meanwhile, after the rural areas have experienced several medical insurance systems including the old cooperative medical insurance system, the new cooperative medical insurance system, we began to further explore and improve the system. With evolution of Chinese medical insurance system, China has entered stage of medical insurance covering all people with formation of three basic medical insurance systems including basic medical insurance for urban employees, basic medical insurance for urban residents and the new cooperative medical insurance for rural residents.With socio-economic development and widening coverage of medical insurance, the co-existence of different medical insurance systems that are unfair between urban and rural areas, can not meet requirements of social development and people security, hindering development of medical insurance. What are reasons behind the problem? How to integrate the existing medical insurance systems and administrative resources from perspective of fairness and efficiency? Is it economically feasible at present stage for Jiangsu Province to follow the reform idea of coordination brought forth by central government? How to stipulate specific system of urban and rural coordination of medical care security?The dissertation studies on basic medical care security system of Jiangsu Province in an effort to present a feasible framework for Jiangsu Province. It has been proven in practice and theory that it is now possible for Jiangsu Province to implement a unified basic medical care security system for both urban and rural areas. The dissertation is consist of eight parts. Below are main research results.PartⅠExisting problems of current basic medical care security system in Jiangsu ProvinceBased on survey and research, analyzing by the method of Health Systems Diagnostic Tree, the dissertation points existing problems of current system of basic medical care security system in Jiangsu Province, including the following aspects of funds-raising, administration and reimbursement.At current stage, great changes have taken place in rural areas of Jiangsu Province in terms of social structure. The three basic medical insurances are designed on different principles of cities and rural areas, and the participants are based on personal identification, which can not meet the requirements of medical insurance from people with different income levels, goes against the trend of social development as well. Because of the low level of coordination, the funds-raising standards vary greatly from one city or county to another, which results in unfairness of funds-raising in different areas. Especially the enormous gap in funds-raising level and financial subsidies of south, middle and north of Jiangsu Province causes more financial pressure to people with lower income, which is against their benefits. Besides, unreasonable funds-raising scheme undermines risk resistance capacity of medical insurance funds. At present, the three basic medical insurance systems of Jiangsu Province are principally arranged at city or county level. For most regions, there are several administrative departments in charge of medical care security system. While the department of labor security is responsible for basic medical insurance system for urban employees and residents, the department of public health care administers new cooperative medical insurance for rural areas, which causes much inconvenience in administering the three basic medical insurance systems, improves administrative cost, reduces administrative efficiency, and finally prevents people from getting access to basic medical care security equally. From the point of the reimbursement level, the current medical insurance systems have crossed coverage and security objects. Complicated insurance patterns exist in different regions. Moreover, different local financial conditions results in an enormous gap in terms of coverage in different regions. As a result, residents can not get equal access to basic health services, contrary to the principle of fairness and reduce the enthusiasm of insured.Depends on the analysis above, the dissertation proposes the necessary of urban and rural coordination of medical insurance.PartⅡThe urban and rural coordination of basic medical care security system has raised regional medical insurance and the benefit level.In the dissertation, a theoretical model is used to illustrate that the urban and rural coordination of medical care security system can bring benefits in three aspects. At first, the fund management functions of the new cooperative medical insurance for rural residents are separated from the health sector, so the third parties can play more effective regulatory functions. Though the improvement of payment and mechanism of negotiating, it can effectively control the induced demand and moral hazard of the doctor as well as the unnecessary medical consumption and the price of medical services which enhanced the welfare of consumers. At second, the coordination can improve the reimbursement for the medical insurance. So it can effectively share parts of the burden of health care of insured. At last, the integration of the administration for urban and rural areas is propitious to reasonably integration and effectively use the management resources, such as human, finance, material and so on. It can also lower the duplicate insurance issues which caused by the division of information systems. It can reduce the difficulty of the health care work, management costs. All of these can raise the treatment of the health care and the overall level of benefits of insured.Based on field investigation in Jiangsu Province, the dissertation employs positive method to prove that given funds-raising standard and maximum reimbursement, the security rate in places where urban and rural medical insurances are administered by identical departments is 8.13 percent higher than that in places where urban and rural medical insurances are administered by different departments.The unity of basic medical insurance administrative departments can raise efficiency, reduce resource waste. It indicates that the urban and rural coordination of medical care security system can solve some problems in the current medical care security system in Jiangsu during the operation.PartⅢVerify that whether Jiangsu Province is able to implement the coordination for basic medical care security system for urban and rural areas at present stage.Because of the regional difference in Jiangsu province, there’re large gap in regional economic development. Generally speaking, the economic in the south regional has been better than it in the north. According to the economic development, it’s been divided into three regions:the north regional of Jiangsu, the middle regional of Jiangsu and the south regional of Jiangsu. Although the urban and rural coordination of medical care security system is an alternative solution, whether it can be done in this place with a gap in economic development remains to be verified. We will explore in detail main obstacles facing the urban and rural coordination of medical care security system in Jiangsu Province from such four viewpoints as finance, urban-rural income gap, fairness of resource allocation and transfer continuum of medical insurance.From perspective of relationship of economy and coordination of medical care security system, when GDP per capita has reached a higher level in Jiangsu Province, it is feasible for the province to implement urban and rural coordination of medical insurance in spite of relative disparity of economic development. In consideration of disparity and correlation of urban-rural income, it is necessary to establish an indiscriminated, tailor-made system of medical insurance that fits for all people. Jiangsu Province has taken the lead in terms of fairness of medical resource allocation. With the condition that the fairness is gradually enhanced, the province can pioneer to implement the urban and rural coordination of medical care security system in China. At present, Jiangsu Province has piloted the program of "to receive medical service out of one’s hometown". It will be implemented in whole province in short term, which will provide a foundation for system and settlement platform of urban and rural coordination of medical care security system.The analysis of these factors indicates that Jiangsu Province is able to implement the urban and rural coordination of basic medical care security system at current stage.Part IV Basic ideas on urban and rural coordination of basic medical care security in Jiangsu ProvinceThe design of medical care security system is mainly related to two issues: funds-raising and reimbursement scheme. The principles of design should follow the minimum efficiency loss and the most equitable form of organization. It should not result in the inflated medical expenses, and should effectively solve the medical burden of insured residents. Through the calculation, the standard of funds-raising and reimbursement scheme of different combinations of health insurance contracts is as followed:the criteria of personal funds-raising scheme of selective health insurance contracts of class A is 350 yuan (include serious illness insurance). The total amount of the corresponding payment base set at 1750 yuan. The corresponding rates of reimbursement should also be increased to 75%-80%. The minimum reimbursement set at 400,600,1000 yuan and the maximum reimbursement set at 180000 yuan. The rates of reimbursement of class B should be increased to 50%-55%. The minimum reimbursement set at 300,500,1000 yuan and the maximum reimbursement set at 100000 yuan. The criteria of corresponding funds-raising scheme should be set at 400 yuan:200 yuan is for the person, and the rest for the government. The criteria of personal corresponding funds-raising scheme of class C should be set at 60 yuan and the rest 200 yuan is for the government, so the total is 260 yuan. The corresponding rates of reimbursement should also be increased to 35%-40%. The minimum reimbursement set at 300,450,1000 yuan and the maximum reimbursement set at 70000 yuan.On basis of studying at the income levels of social group and their demand for health insurance, a basic idea of framework for urban and rural coordination of basic medical care security system is put forward in the dissertation, which is characterized by multiple level, free option, whole coverage, coordination at province level, suitable security.更多还原