【作者】 周绿林；

【导师】 梅强；

【作者基本信息】 江苏大学 ， 管理科学与工程， 2008， 博士

【摘要】 医疗保险费用从广义上来理解,是指参保人患病后发生的医疗费用总和。医疗保险费用控制则是医疗保险费用支出管理的一项重要手段。控制的对象是医疗保险范围内的各类医疗费用,控制的目的是为了最大限度地实现医疗保险保障基本医疗的宗旨,维护参保人员的基本权益。医疗保险费用控制是世界难题,其重要性和意义不言而喻。建立医疗保险费用控制机制是医疗保险制度本身正常运营和可持续发展的需要;是确保医疗保险基金收支平衡的重要措施;是处理好医、患、保三方关系,维护参保人员权益和社会稳定,构建“和谐社会”的重要保证;是积极推动“三改同步”,真正建立独立于企事业单位之外的社会医疗保险制度的必须。控制医疗保险费用成为当今世界各国,尤其是中国面临的重要问题和难题。因此,开展医疗保险费用控制研究,构建医疗保险费用控制机制,有效控制医疗保险费用,使广大居民获得最大限度的医疗保险待遇,不仅具有重要的理论价值,而且具有重要的现实针对性。医疗保险费用控制涉及的相关理论有:疾病风险理论、医疗保险需求与供给理论、大数法则理论、博弈论、健康管理、控制论等,本文进行了阐述和分析。运用多元线形回归模型,建立了需方、供方和医疗保险费用的关系,明确了影响医疗保险费用增长的主要因素。同时利用时间序列法对未来5年医疗保险费用的走势进行预测。研究表明,过去的十年里我国医疗保险费用呈直线上升趋势。医疗保险费用的增长与平均每所医院的业务收入、政府卫生支出比例以及人均卫生费用等因素成正相关关系,与卫生机构卫生技术人员数、居民消费价格总指数成负相关关系。医疗服务和医疗保险领域存在的自然垄断与价格刚性、信息不对称导致的诱导性需求以及道德风险等因素是现阶段我国医疗保险费用控制的难点。国际上,医疗保险的费用控制手段多种多样,归纳起来主要有三大类:宏观控制以及对医疗保险供需两方的控制。医疗保险费用控制机制的发展趋势是:从侧重需方控制向侧重供方控制发展;从数量性控制向结构性控制发展;从限制性控制向诱导性控制发展;从司控与被控的关系向共同控制的协同关系发展;从三角关系向双边关系发展。论文同时研究了典型国家医疗保险费用控制经验及对我国的借鉴。进入上世纪八十年代以来,国际上医疗保险支付方式发生了很大变化,呈现出以下的发展趋势:支付方式从后付制向预付制发展;支付标准从自由定价向政府控制价格或统一价格发展;支付模式从全部支付向部分自付制发展;支付体制由分散独立向集中统一发展。在选择医疗保险支付方式时,应当考虑以下三点:一是对不同的供方组织采取不同的支付方式;二是对特定的供方也可以采取混合的支付方式;三是在支付方法上,可以根据提供服务的不同而采取不同的方式。运用博弈论的方法分析政府与医疗保险机构之间、医疗保险机构与医疗服务提供方之间、医疗服务需求方与提供方之间、医疗保险机构与医疗服务需求方之间利益分配的动机和决策。并对医疗保险费用控制进行混合博弈分析。论文对国务院医改试点城市——镇江市医改试点十余年来在医疗保险费用控制方式上的探索与实践以及控制特点等进行了研究,镇江市医疗保险费用控制方式已由试点初期的“按服务单元付费”发展为现在的“综合控制”。通过对费用控制效果进行的综合评价和分析表明,镇江市医疗保险费用控制效果是好的。论文最后提出了医疗保险费用控制的基本原则和一系列控制措施。包括:强化对医疗保险费用的宏观控制,强化对医疗保险四方的控制,强化对医疗保险费用支付方式的改革,强化对医疗保险中道德风险的控制,强化健康管理对医疗保险费用的控制。更多还原

【Abstract】 Broadly speaking, medical insurance expenses means the total sum of medical expenses after the insured person’s illness .The control of medical insurance expenses is an essential tool for the management of medical insurance expenditure. The controlled object is the various types of medical expenses in the scope of medical insurance. The purpose is to achieve the principle of maintaining the basic medical care and safeguarding the fundamental rights of the insured people to the largest extend.The control of medical insurance expenses is a universal problem and its essentiality is self-evident. The establishment of a controlling mechanism of medical insurance cost aims at maintaining the basic operation and sustainable development of itself, ensuring the balance of payments of the fund, handling the relationship among the doctors, patients and insurers, safeguarding the rights and interests of the insured , establishing a harmonious society, promoting the "three simultaneous reform" and truly establishing an independent social medical insurance system which is out of the control of enterprises and institutions.The control of medical insurance expenses has become an important issue in the worldwide range, especially for China. Therefore, it is of significant theoretical value and important realistic pertinence to develop the research of medical insurance expenses control, establish a medical insurance expenses controlling system so as to control the medical insurance expenditure effectively and to make sure the vast majority of residents can receive medical insurance to the maximum scale.This paper expresses and analyzes the reverent theories of medical insurance expenses control, such as disease risk theory, the supply and demand theory, large numbers rule, game theory, health management and cybernetics.This paper uses the model of multiple linear regressions to establish the relationship among demander, supplier and medical insurance expenses, making clear the main factors that affect the increase of medical insurance expenses. Meanwhile, the author predicts the trend of expenses in the following five years by using the time series method.The research shows that China’ s medical insurance expenses showed a go-up tendency in the past ten years. There is a positive correlation among the medical insurance expenses, the average income of per hospital, the proportion of government expenditure on health, and the per-capita health expenses. There is a negative correlation among the medical insurance expenses, the number of the health technological personnel, and the total price-index of citizen consumption. The difficulties lies in the natural monopoly and the price rigid, the induced medical demand and virtue risks caused by information asymmetry existing in the fields of medical service and medical insurance.There are various tools used for medical insurance expenses control in the world. They can be divided into three categories: macroscopic control and the control of the demanders and the suppliers in the medical insurance. The tendency of medical insurance expenses controlling mechanism is transferring from emphasizing the control of demanders to the control of suppliers, from the control of quantity to the control of structure, from the control of restriction to the control of inductivity, from the relationship of take and receive control to the collaborative development of mutual control, from the triple coordinated relationship of the insured, the assured and the medical service suppliers to bilateral relationship of the medical insurance organization and the service suppliers and demanders. This paper also researches the experience of typical countries in their medical insurance expenses control which we can learn from.From 1980s, the means of medical insurance payment had undergone tremendous changes. This article shows the development trend and they can be summarized as below: the mean of payment changing from after-payment to prepayment, the standard of payment changing from free pricing to government control price or unified price, the mode of payment changing from paying in full to partially self-paid, the system of payment changing from dispersion and independent to centralized and unified. When choosing the means of medical insurance payment, we should consider the following three points: firstly, choosing the different payment models for different supply organizations; secondly, using the mix payment means for specific suppliers; thirdly, taking the suitable methods in payment according to the different service supplied.This paper uses the game theory to analyses the motivation and decision of benefit distribution between the government and the medical insurance organization, between the medical insurance organization and the supplier of medical service, between the demander and the supplier, and between the medical insurance organization and the demander of medical service. It also uses the mixed game theory to do some research on the medical insurance expenses control.This paper introduces the example of Zhenjiang, one of the medical innovation of pilot cities, describing its exploration and practice in its medical insurance expenses in the last decade year. The method of its medical insurance expenses control has evolved from"Fee for Service Unit" to "Integrated Control". Through the comprehensive evaluation and analysis of the effect, we find that Zhenjiang’s medical insurance expenses control model is the best one in China.This paper puts forward some basic principles and a series of control methods for the medical insurance expenses control in the end which includes the strengthening of the macro-control of medical insurance expenses, enhancing the control of the four aspects of medical insurance, accelerating the reform of expenses payment means, promoting the control of moral hazards in medical insurance, intensifying the control of medical insurance expenses by using health management.更多还原