【作者】 张海冰；

【导师】 汪克夷；

【作者基本信息】 大连理工大学 ， 企业管理， 2010， 博士

【摘要】 随着经济社会的不断发展,社会医疗保障制度的建立与完善已经成为社会文明进步的重要标志。它不仅对提升人民整体健康水平具有重要意义,同时也是推进全面建设小康社会、构建和谐社会的巨大动力和有利保障。本文从社会医疗保障全民覆盖的角度出发,对实现这一体系的制度构想和政策设计进行了探索。并以大连市为例,在对大连市具体的情况统计与数据分析的基础上,进行全覆盖模式下的收支平衡研究。首先,通过比较国内外医疗保险运行模式的情况,发现我国医疗保险制度与国外先进制度相比存在的不足,并根据我国的实际情况进行一定的经验借鉴。同时,本文在我国医疗保险模式的运行现状及其成因分析的基础上,对医疗保险的全覆盖模式进行了构想,设计了覆盖城镇职工、未成年人和大中专学生、农民工与失地农民等不同群体的多维体系,以实现医疗保险的全民覆盖。其次,在医疗保险全覆盖模式设计的基础上,本文针对我国目前医疗保险基金的收支情况进行了研究。在总结我国历年的收支结余情况的同时,比较北京、上海、无锡、镇江和大连等不同地区的差异,得出影响基金收支平衡的因素主要包括政策、经办机构和人口老龄化因素等,并进一步提出克服不利因素、实现收支平衡的对策建议。最后,以大连市为例,运用数学建模的方式,构建收支平衡的医疗保险全覆盖模式。研究发现,大连市目前的医疗保险基金结余率达23.65%,远高于国家规定的15%,医保基金结余过多,造成社会资源的严重浪费。本文针对于此,结合造成收支不平衡的根本的政策因素及结算因素,通过研究医疗保险基金的征缴额以及医疗费用的支付额相关性,理清医疗保险基金的收支关系。设计了面向广泛的参保人员,降低基金结余,缓解居民医疗费用负担,实现医保基金收支平衡的模型。并引入“承载力系数”这一概念,通过调节这一变量,以达到收支平衡的效果。本研究主要运用文献分析和数学建模的方法,围绕我国医疗保险制度的全覆盖模式和医疗保险基金的收支平衡问题展开。在设计符合我国国情的医疗保险全覆盖体系的同时,也提供了解决目前医疗保险基金收支失衡、缓解参保人员医保费用过重,实现医疗保险基金收支平衡的模型,为医疗保险领域的进一步研究提供了理论依据和分析工具。更多还原

【Abstract】 With the continuous development of social and economic progress, improving the social medical insurance system has become an important symbol of social civilization and progress, which not only improves the health level of the overall people, but also promotes the well-off society and builds a harmonious society.It explores the realization of social health insurance under full-covered systems concept and policy design from the view of the social point. It cites an instance of Dalian, puts up the studies on the balance of full-coverage mode, which bases on the specific situation statistics and data analysis.Firstly, comparing the medical insurance operation mode between domestic and abroad countries, finds that the weaknesses of our medical insurance system compared with foreign advanced system, and draws lessons from the foreign experience. At the same time,it conceives the full-covered health insurance mode, which bases on the analysis of the current situation and formation reasons, and designs multidimensional systems which covering the urban workers, minors and in college students, migrant workers and landless peasants, in order to achieve universal health insurance coverage.Secondly, it studies the income and expenditure status of the current health insurance fund based on the design of the universal health insurance coverage. In summing up the balance situation over the years, compares the differences among Beijing, Shanghai, Wuxi, Zhenjiang and Dalian, obtains the major factors of the balance of the fund payments, which includes policy, management agency and the population aging, and comes up the countermeasures of overcoming the negative factors and achieving a balanced budget.Finally, cites the instance of Dalian, uses the mathematical modeling approach to construct the whole balance of health insurance coverage patterns. It finds that Dalian current rate of medical insurance fund balance is 23.65% which far higher than the national requirement of 15%, excessive medical insurance fund balance results in a serious waste of social resources. It combines with the policy factors and settlement factors which leading to the fundamental imbalance, and researches the relativity between the collection amount of medical insurance fund and the payments of medical expenses, sorts out the balance of medical insurance fund. It designs the medical insurance fund balance model which covers a wide range of insured people and reduces the surplus fund to ease the burden on residents of medical expenses, achieves the balance of medical insurance fund. It introduces the concept of "capacity factor", achieves the break-even results by adjusting the variables.By literature analysis and mathematical modeling, it carries on the research of medical insurance system for China’s full-covered model and medical insurance fund balance issues.In the design of health insurance system under full-covered which according with our national conditions, at the same time, completes the model of medical insurance system undered full-covered, which provides a solution to the current imbalance between revenue and expenditure of medical insurance fund, relieves the overweight insured health care costs, provides a theoretical basis and analysis tools for further studies on the social medical insurance.更多还原