【作者】 张磊；

【导师】 顾海；

【作者基本信息】 南京大学 ， 社会医学与卫生事业管理， 2013， 博士

【摘要】 自1998年开始的城镇职工基本医疗保险制度改革、2003年新型农村合作医疗制度及2007年城镇居民基本医疗保险制度的分步试点与推进,中国已初步建立起了缴费型的社会医疗保险体系,全民医保的雏形已基本确立。但是在全民医保体系建立过程中存在着很多的问题,公平性问题没有得到很好的解决,筹资压力大,医保基金难以收支平衡,付费机制不完善,医疗机构改革没有实质性进展,群众“看病贵、看病难”的问题依旧突出。随着新医改的实施,建立全面覆盖的可持续发展的基本医疗保险制度是实现全民医保目标的必然选择。而医保基金的有效平衡运行是维持社会医疗保险制度正常运转和可持续发展的一个重要方面,医保基金的筹集、补偿与管理是社会医疗保险可持续发展的基础和物质保障。当前社会医疗保险面临较大的压力,这种压力源于医疗服务费用的快速上涨、老龄化带来的高昂医疗费用、居民健康意识增加带来的医疗需求的释放、生活习惯改变所导致的慢性病发病率的增加、医学技术的进步导致的昂贵治疗措施等。本文首先从社会学、心理学、经济学的角度对社会医疗保险基金的承受力进行了界定,分析认为社会医疗保险基金的承受力是指在国家、企业与个人风险共担的筹资机制下,政府运用其行政主导与管理能力,制定与国家社会经济发展水平相适应的补偿政策,支付参保人基本医疗服务需求的费用,满足参保人基本医疗服务需求的能力,具体表现为社会医疗保险基金在一定筹资水平、补偿能力和管理水平下满足参保人医疗服务需求的能力。在此基础上,本文研究内容主要分为三大部分。第一部分探讨社会医疗保险基金承受力影响因素。社会医疗保险的禀赋资源是决定其承受力的关键因素,本部分结合可持续发展的思想,从宏观和微观两方面论证社会医疗保险的承受力,分析社会医疗保险基金尤其是基金制度管理的自我平衡原理,研究内生变量和外生变量对社会医疗保险承受力的影响,进行逻辑演绎,探究影响医保基金筹资、补偿与管理因素对医疗保险可持续发展的作用机理。通过文献梳理与问卷调查的方式搜集当前尽可能多的影响医保基金承受力的影响因素,对文献和调查过程中主要的因素进行理论上的论述,分别对其影响医保基金承受力的机理进行分析,在此基础上运用统计学因素缩减的方式,将调查的因素进行合并与缩减,将较多的影响因素合并为几个较少的公共因子。利用公共因子与基金结余率构建误差修正模型,得出医疗保险基金承受力短期和长期的均衡模型,进而可以分析短期和长期不同因素的作用机制。第二部分构建社会医疗保险基金承受力评价指标。当前承受力评价指标在区域环境、生态与经济范围研究较多,在医疗保险领域目前还没有专门评价社会医疗保险基金承受力及可持续发展的评价体系。本部分内容将借鉴可持续发展评价体系建设的内容,构建适应于我国社会医疗保险基金承受力的可持续发展指标。在比较当前国际上几个主流的评价压力与环境之间的模型之后,本文选取PSR模型作为构建评价指标的理论模型,通过层次分析法对指标的权重进行设定,再此基础上通过横向的区域比较和纵向的时间预测比较,评价江苏省社会医疗保险基金承受力的状态,并通过比较PSR模型中各个要素的得分发现现在及将来江苏省社会医疗保险基金承受力所面临的问题及缺陷。第三部分是社会医疗保险可持续发展的实现。社会医疗保险基金的可持续性在于医疗保障水平与社会经济的发展保持协调,本部分在承受力的客观评估和预测的基础上,分析未来的内外部环境和医保基金筹资、补偿与管理政策的发展趋势,结合第二部分所分析医保基金存在的缺陷,分析政策优化路径并提出社会医疗保险的可持续发展的对策与建议。更多还原

【Abstract】 Since1998, the urban basic medical insurance system reform, in2003the new rural cooperative medical system and in2007the basic medical insurance system for urban residents in the pilot and advancing step by step, China has initially established a contributory social health insurance system, prototype of universal health care has been basically established. But in the process of establishing universal health care system, there are many issues, fairness issues have not been satisfactorily resolved, raising pressure, health insurance fund is difficult to balance, pay mechanism is imperfect, no substantive progress in reform of medical institutions, and the masses." medical care, medical treatment is difficult "issue is still outstanding. With the implementation of the new health care reform, the establishment of a comprehensive coverage of sustainable development of the basic medical insurance system is to achieve universal coverage goals inevitable choice, and run health insurance fund is to maintain an effective balance of social medical insurance system functioning and sustainable development is an important, the health insurance fund raising, compensation and management of social health insurance foundation for sustainable development and material security.Current social health insurance face greater pressure, which stems from the rapid rise in health care costs, an aging brings high medical costs, increased health consciousness residents brought the release of medical needs, lifestyle changes lead to chronic diseases increase in the incidence, advances in medical technology led to expensive treatment measures. Firstly, from sociology, psychology, economics point of view of social health insurance fund has defined the affordability analysis that the social medical insurance fund endurance refers to the state, enterprises and individual risk-sharing financing mechanism, use its executive-led government and management capacity to develop and national socio-economic development level of the compensation policy, the insured person to pay the cost of basic medical services to meet the basic medical needs of the insured person’s ability, as demonstrated by the social health insurance fund at a certain level of funding, compensation and management levels to meet the medical needs of the insured person’s ability. On this basis, this paper mainly divided into three parts.The first part discusses the social medical insurance fund endurance impact mechanism. Endowments of social health insurance is to determine the key factors of its affordability, this part of the idea of sustainable development, both from a macro and micro demonstrate the affordability of social health insurance, analysis of social health insurance funds, especially self-managed fund system balance principle, study endogenous and exogenous variables on the social impact of health insurance affordability, logical deduction, explore funding affecting health insurance fund, compensation and management factors on the health insurance mechanism of action for sustainable development. Through literature review and questionnaire survey to collect as much as possible the impact of the current health insurance fund endurance factors, during the investigation of the literature and a major factor in a theoretical discourse, namely health insurance fund their impact analysis of the mechanism of tolerance, on the basis of the factors that reduced the use of statistical methods, will investigate the factors that consolidation and reduction, the more factors into several less common factors. Use of public fund balance ratio factor and build error correction model, derived MBF endurance short and long term equilibrium model, in turn, can analyze short-and long-term mechanism of action of different factors.The second part of the social medical insurance fund to build endurance evaluation. Current endurance evaluation at the regional environment, ecology and economy-wide study more, in the medical insurance field is currently no specific evaluation of social health insurance affordability and sustainability of the evaluation system. This section will draw on the Sustainable Development of the contents of system construction, the model built to adapt to China’s social medical insurance fund to withstand the force of sustainable development indicators. In comparing the current international pressure on the evaluation of several mainstream models with the environment, the paper selected PSR model as a theoretical model constructed evaluation by AHP weights on the indicators set, and then passed on the basis of transverse regional comparative and longitudinal time prediction was evaluated by comparing the social medical insurance fund, Jiangsu Province, the state of endurance, and PSR model by comparing the scores of each element found in present and future social health insurance fund, Jiangsu Province, the problems faced by endurance and defects.The third part is the social health insurance to achieve sustainable development. Sustainability of social health insurance fund that level of medical care and social and economic development in harmony, this section in endurance objective assessment and prediction, based on the analysis of the internal and external environment and the future financing of health insurance fund, compensation and management policy trends, combined with the second part of the analysis of defects in medical insurance fund and the government in the Medicare fully explored the role of sustainable development, policy analysis and propose optimal path for sustainable development of social health insurance countermeasures and suggestions.更多还原