【作者】 陈一丹；

【导师】 卢祖洵；

【作者基本信息】 华中科技大学 ， 社会医学与卫生事业管理， 2009， 博士

【摘要】 研究目的本研究从我国现阶段医疗保险改革的制度框架和总体要求出发，对照国内其他先进省市实施医疗保险制度的一些做法，总结珠海市医疗保险制度模式，分析珠海市保险基金的运作情况、研究珠海市医疗保险政策对医疗费用的影响等等，找出其模式存在的问题及其原因。在此基础上，提出进一步完善珠海市基本医疗保险制度的对策，为政府决策提供参考依据。研究内容1、社会医疗保险理论探讨2、珠海市社会医疗保险政策发展状况及评价3、对珠海市医疗保险模式进行总结4、珠海市城镇职工医疗保险系统动力学研究5、珠海市医疗保险政策对医疗费用的影响研究方法1、文献回顾性研究2、系统动力学研究3、定量分析研究结果1、2003～2007年珠海市社会医疗保险覆盖率分别为：48．6％、54．2％、60．5％、68．8％、76．2％，并且参保人数的增长速度远远大于户籍人口增长速度。珠海市医疗保险的参保人数在五大社会保险中历年排名第二，且历年的参保人数平均增长速度高于其他社会保险。2、2003～2007年间，珠海市各类医疗保险享受待遇人次每年均有增长，以2008年人次最多，为52187人；其社会医疗保险基金结余总额分别为：6341、4715、5883、7454、17776万元，医疗保险基金收入、支出及结余的年平均增长速度变化均不大，比较稳定。3、珠海市城镇职工医疗保险单位缴费比例为7％，低于苏州市、成都市、厦门市；其缴费基数的下限规定为工资基数的80％，高于其他三城市的60％。珠海市个人账户金额为工资总额的3％-4％，低于厦门市。珠海市外来人员只能参加大病医疗保险，不能参加基本医疗保险，未成年人和城乡居民医疗保险存在覆盖人群不足。相对与各地的财政收入而言，珠海市外来人员医疗保险、未成年人医疗保险、城乡居民医疗保险的财政补助和医疗待遇低于其他三城市4、系统动力学分析表明，珠海市到2017年户籍总人口将达102．127万人，国内生产总值将达到3597亿元，城镇职工医疗保险基金将达到502356万元。基金总量受国内生产总值的影响很大。5、医保病人和自费病人住院费用结构对比分析结果表明：药品、护理、床位费用是影响医保患者住院人均消费的前三位因素；床位、药品、护理是影响自费患者住院人均消费的前三位因素。6、协方差分析表明：部分医保住院病人每日住院费少于自费病人，但是医保病人住院总天数普遍大于自费病人。研究结论1、由于珠海市城镇职工基本医疗保险工作开展时间早、建立多层次的社会医疗保险制度早以及财政收入的高增长和人口的低增长给扩面工作带来了便利等原因，使珠海市社会医疗保险覆盖率步入全国前列。2、珠海市制定的《珠海市社会保险反欺诈办法》、市社会保险基金监督委员会的监督以及社会医疗保险中心的良好管理工作确保了珠海市社会医疗保险基金运行基本平稳。3、对珠海市城镇职工医疗保险基金进行系统动力学分析表明：国民经济健康发展是医疗保险系统有效运行的基础；在重视医疗质量前提下，才考虑基金总量增加；在保证基金有效运作的同时，应继续扩大受保面。4、珠海市医疗保险政策制定思路不一致，其城镇职工基本医疗保险政策部分不符合时代发展，住院病人个人自付比例较低，参保人享受待遇水平偏高。外来人员缺少基本医疗保险，未成年人和城乡居民医疗保险财政补助力度偏小，参保人享受待遇水平也偏低。5、珠海市门诊医疗费用实行项目结算、住院医疗费用实行定额结算以及加强对定点医疗机构的监管等政策使部分医保住院病人每日住院费少于自费病人，但是医保病人住院总天数普遍大于自费病人。建议1、统一医疗保险制定的思路，将外来人员纳入基本医疗保险中，分不同人群不同的缴费标准和医疗待遇标准，制定“统一式”的社会基本医疗保险管理办法。2、提高城镇职工医疗保险的自付比例，提高未成年人和城乡居民医疗保险财政补助力度及其享受待遇水平。3、进一步控制药品费在医保病人住院消费中的比重，加强每种疾病住院总天数的限制以减低医保病人的住院医疗费用。4、通过建立起真正的医疗卫生体制市场机制、返还保险费、完善支付模式、加强对医疗基金的审核监管机制、改革医疗报酬体系等措施来控制医疗费用并且提高医疗服务质量。研究的创新点1、引入社会医疗保险覆盖率的概念及计算方式，具有独创性。2、对珠海市医疗保险体系模式进行了系统的分析并且与其他先进城市比较，尚未发现同类研究。3、采用系统动力学的方法分析医疗保险基金运行情况，具有部分创新性。4、通过对医保病人和自费病人费用结构、日住院费用和住院天数进行比较，分析医保政策对医疗费用的影响，尚未发现同类研究。不足与需要继续开展的研究1、由于时间、经费的局限，调查研究样本限于珠海市人民医院。鉴于医疗机构存在规模和级别的差异，难以完全代表医保政策对医疗费用的影响。2、限于时间和能力，本课题没有对珠海市医疗保险基金收缴模式和收缴比例(数量)进行详细研究，对于财政补助比例、支付比例确定等等也缺乏详细深入的研究。这些均有待今后进一步研究。更多还原

【Abstract】 ObjectivesThe aim of the study was to summarize the characteristics of ZhuHai City health insurance system model, to analyze the operation status of ZhuHai City health insurance fund, to study the influence of ZhuHai City health insurance policy on the medical expenditure and to find out the problems and causes of them, on the base of the requirement and framework of prevalent Chinese health insurance reform and in reference to the practices of health insurance implementation in other advanced provinces. Countermeasures were put forward to provide reference for the government policy-making in order to improve the basic health insurance system of ZhuHai City.Contents1. The discussion of the Social Health Insurance theory.2.The development and evaluation of ZhuHai City health insurance policy3. The characteristics summarization of ZhuHai City health insurance model4. The systematic dynamics study of ZhuHai City Worker Basic Health Insurance5. The impact of the ZhuHai City health insurance policy on the medical expenditureMethods1. literature review2. System dynamics3. Quantitative analysis system of ZhuHai City.Results1.The rate of Zhuhai City Social Health Insurance from 2003 to 2007 respectively were 48.6%, 54.2%, 60.5%, 68.8%, 76.2%, and the increasing speed of the insured population surpassed that of the population in census register. The insured population ranked second in the five social security insurances in the passing years, and the increasing rate of the insured was higher that those of the other social security insurance.2.From 2003 to 2007, the compensated people was increasing yearly for the various city health insurances in Zhuhai City, and it reached the highest in 2008, that is 52187 people; the surplus of Social Health Insurance Fund respectively were: 6341, 4715, 5883, 7454, 17776 ten thousand yuan; it was very steady for the changes of average yearly increasing rates of the income, the expenditure and the surplus of the Fund.3.The premium rate of the City Worker Basic Medical Insurance (CWBMI) for the employer was 7%, which was lower than those of Suzhou City, Chengdu City, and Shamen City; the lowest line of the premium for the employee was 80% of the basic salary of the insured worker, which was 60% higher than those of the other cities. The income of the individual account of Zhuhai City CWBMI was 3% to 4% of the salary of the insured worker, which was lower than that of Shamen City. The foreign population could only join the serious disease insurance instead of the basic health insurance, and the coverage of the juveniles and city citizens was insufficient in Zhuhai. Comparing the fiscal income of Zhuhai to those of the other three cities, the fiscal subsidies and the enjoyed benefit package of the medical insurance of foreign population, the juveniles and city citizen were lower than those of the other three cities.4.The systematic dynamics analysis showed that the population in census register would reach 102.127 ten thousand people in 2017 in Zhuhai City and the gross national product would reach 3597 billion yuan, and the CWBMI Fund would reach 502356 ten thousand yuan. The total Fund would be affected by the gross national product.5.The components of inpatient expenditure of the insured and non-insured showed that the expenditures on drug, care and bed ranked the first three factors which affected the average expenditure of insured inpatient while the expenditures on bed, drug and care ranked the first three factors which affected the average expenditure of non-insured inpatient.6.The covariance analysis showed that the part of the daily inpatient expenditures of the insured was lower than that of the non-insured inpatient, but the average length of the stay of the insured patients was longer that that of the non-insured patients.Conclusions1. The coverage of ZhuHai City Social Health Insurance reached 76.2% of the whole population due to the early start of The City Worker Basic Health Insurance, the establishment of multiple levels of Social Health Insurance, the high growth of the fiscal income and the low growth of the population. The favorable conditions made the health insurance work launch conveniently, which made ZhuHai City advanced all over the country.2. The stable operation of ZhuHai City Social Health Insurance fund was guaranteed by the Law of ZhuHai City Social Health Insurance against Cheating, the supervision of the ZhuHai City Social Health Insurance Supervision Committee, and the efficient work of the Social Health Insurance Center.3. The systematic dynamics study of ZhuHai City Worker Basic Health Insurance Fund showed: The healthy development of the national economy was the base for the effective operation of the health insurance system; the total increase of the Fund was considered on the premise of emphasizing the medical treatment quality; the coverage of the Social Health Insurance should be enlarged further while effective operation of the Fund being guaranteed.4. The policy-making ideas of ZhuHai City health insurance were different from each other; some part of the City Worker Basic Health Insurance policy was not conformed to the development of the time; there was a low copayment for the inpatients while the level of treatment enjoyed by the insured was too high; migrant population lacked the health insurance, and there was a low degree of the fiscal subsidy to the juveniles and the city and town residents and the insured.5. There were the fee-for service payment for the outpatient expenditure, the payment quota for the inpatient expenditure in ZhuHai City, and the enhancement of the supervision policy to the designated health institutions led to that some of the insured patients have less inpatient daily expenditure than that of the out-of-pocket patient, but the average length of the stay of the insured inpatient was longer than that of the out-of-pocket patient.Suggestions1. The ideas of making Social Health Insurance policy should be unified, and the migrant population should be covered by the Social Health Insurance; different populations should be different in standards on the premium and medical treatment, and there should have a "unified" management of Social Health Insurance.2. The copayment level should be increased for City Worker Basic Health Insurance, and the levels of fiscal subsidy and medical treatment of the City Resident Medical Insurance should be enhanced for the juveniles and the residents in the city.3. The proportion of the drug in the insured inpatient expenditure should be contained; the restriction of the length of the stay for every kind of disease should be strengthened in order to reduce the hospitalization expenditure of the insured patients.4. Measures need to be taken to cover the medical expenditure and enhance the medical treatment quality, such as: the measures on the establishment of the true marketing mechanism for the medical treatment and care system, the reimbursement, the improved payment model, the enhancement of the supervision mechanism of the health insurance fund audit, the reform on the medical payment system, etcThe innovationsof the study1. Introduction of the concept of the coverage of the Social Health Insurance and the calculation method, it has originality2. Systematic analysis on ZhuHai City health insurance model and comparison with other advanced cities, similar researchs have not been found.3. The systematic dynamics study method was applied to analyze the operation of the health insurance fund, it has some innovative.4. The similar domestic study has not been found for the impact study of the medical insurance policy on medical expenditure by the comparison of the expenditure components, daily inpatient expenditure and the average length of stay of the insured and non-insured inpatients.The limitations:1. The investigated sampling was limited to ZhuHai City People Hospital due to restriction of time and project fund. Thus, it was hard for this study to represent the impact of the health insurance policy on the medical expenditure as a whole due to the different scale and rank of the medical institutions in ZhuHai City.2. There was no detailed study of the ZhuHai City health insurance fund collecting model and the fund collecting proportion /quantity, the fiscal subsidy proportion, payment proportion determination due to the limitation of the time and energy. All these need to be studied further.更多还原