【作者】 王建；

【导师】 赵黎明；

【作者基本信息】 天津大学 ， 技术经济及管理， 2008， 博士

【摘要】 当前,引起医疗费用不合理上涨的重要根源是因医疗保险体制性缺陷造成的道德风险。这一问题的存在不仅加剧了医疗费用的激增,影响了稀缺性医疗资源的合理配置,而且对医疗保险制度的可持续发展造成了巨大冲击。因此,医疗保险领域的道德风险及其控制问题,是一个具有重要理论意义与实践价值的课题。本文在回顾国内外医疗保险中道德风险的基础上,从医疗服务需求方、供给方、保险机构三方角度,详细分析了当前社会医疗保险领域道德风险不同的表现形式,针对不同表现形式进行原因分析。进一步地,运用经济学经典理论和博弈模型,文章深入挖掘了道德风险产生的深层机理,并基于信任机制理论深入揭示道德风险在医疗保险中造成的影响和危害。在总结国内外规避道德风险经验教训的基础上,依据我国实际情况,论文探讨了我国规避医疗保险领域道德风险的基本思路以及具体对策措施。最后,介绍了天津市建立医疗保险信誉等级制度的一些做法并进行实效分析,旨在检验本文所提出的基本构想的合理性。本文在总结前人有关研究的基础上,所作的创新性研究主要有几个方面:根据制度经济学和社会学关于信任机制的研究,提出道德风险的社会影响一方面是对医疗保险系统制度信任的破坏,另一方面则是对该系统内专家信任的破坏。这一分析较好地解释了我国目前医疗领域广泛存在的医患矛盾等问题;设计了规避道德风险的全新的信誉制度体系,如建立执业医师信誉档案制度、定点医疗机构信誉等级评价制度、保险机构的社会监督制度以及医疗保险基金督察制度等;主张建立参保患者信息档案管理制度,提出参保患者信息档案由参保患者的健康档案和信誉档案为主要内容的全新设想;对医疗卫生体制改革提出了一些独立见解,如提出改革医院等级评定制度和医生职称评定办法,由卫生行业协会评定医疗机构和从业人员的技术资质等级和技术职称,由医疗机构的服务方评价定点医疗机构和从业人员的信誉等级。更多还原

【Abstract】 Nowadays, one of the most important origin of the medical expense irrational rise is the moral hazard problem caused by defects in the medical insurance system. The problem not only sharply increases medical expenses, influences rational distribution of rare medical resources, but also causes great impact on the sustainable development of medical insurance system. Therefore, it is a subject with important theoretical significances and practical values to study the moral hazard problem and its control in the medical insurance.By reviewing the developing processes of the medical insurance systems and the moral hazard problems at home and abroad, the different manifestations with relevant reasons are analyzed in detail from three perspectives of medical service demander, the supplier and the insurance institution.Then, the deeper reasons respectively from the economics mechanism perspective and the game model theory are explained. At the same time, the research deeply discusses the influences caused by the moral hazard form the viewpopint of trust system.Based on the summary of the experience and methods of moral hazard control in the medical insurance both at home and abroad, the research explores the basic thoughts and the concrete strategies of controlling the moral hazard. At last, the research introduces some ways of establishing medical insurance reputation hierarchy and does efficacy analysis which aims at testing the rationality of the basic thoughts mentioned in the research.The innovation of this research mainly includes the following aspects:F irstly,according to the study of the trust mechanism in institutional economics and sociology, the research proposes social influences of the moral hazard. One aspect is the destruction of the trust of medical insurance system; the other is the destruction of the trust of the experts in this system. This analysis explains problems widely existing in medical area well such as the conflicts between doctors and patients nowadays.Secendly,the research designs the reputation system of moral hazard control, for example, establishing reputation achieves system of licensed physicians, evaluation system of reputation hierarchy of fixed medical institutions, social supervisory system of insurance institution, fund supervisory system of medical insurance. The research claims to set up insured patients’information achieves administrating system, and puts forward the brand-new assumption that the insured patients’information achieves mainly includes the health achieves and reputation achieves of the insured patients.Thirdly,the research puts forward some distinctive views of the medical system reform. For instance, the research proposes to reform hospital hierarchy evaluating system and doctors’title evaluation method i.e., the technical qualification hierarchy and technical title of medical institutions and medical staff are evaluated by the health guild, and the reputation hierarchy is evaluated by the medical institution service supplier.更多还原