【作者】 冯英；

【导师】 罗遐； 吴群；

【作者基本信息】 安徽大学 ， 公共管理， 2011， 硕士

【摘要】 近年来,社会医疗保险道德风险行为不断被媒体曝光,引起了社会的普遍关注。这些行为严重侵蚀社保基金并损害医疗保障体系公平,已经影响到医保制度的平稳运行,对其有效的控制与约束是保障基金安全和制度良性运行的前提。而由于医疗行为的高度专业性、医疗服务的异质性、医疗服务的需求弹性和医疗信息的高度不对称性,使得社会医疗保险道德风险行为具有相当的隐蔽性；医疗保险第三方付费方式,这种制度本身的设计缺限给医患双方都有利可图,骗保成本过低、医疗消费的伦理色彩以及医疗消费的不确定性,使得风险控制成为理论和实践操作上的难题。本文通过对芜湖市近年来医疗保险查处中得到违规案件,对医疗保险道德风险的表现进行了分类,分别从医疗保险供方、需方以及供需方合谋三个方面介绍了医疗保险道德风险主要表现形式,通过典型案例和数据进一步论证医疗保险领域道德风险的种种表现和特点,并揭示道德风险的产生的原因。笔者结合多年来从事医疗保险方面的工作经验,将综合运用经济学、管理学等学科的相关理论,着重从理论基础、医保制度因素、医院补偿因素、监管因素、道德因素、成本因素等方面对医疗保险道德风险的成因进行深入的剖析,最后从体制、法律规范、政策引导、技术、监管、道德等方面提出了防范医疗保险道德风险的建议。更多还原

【Abstract】 In recent years, the issue of moral hazard in social medical insurance was frequently reported and covered via various medias, which attracted public general concern of the whole society. These immoral behaviors had seriously eroded social insurance fund, doing harm to the justice of medical security system and preventing the smooth operation of medical insurance system. Therefore, effective control and constraint on moral hazard are essential to safeguard medical fund safety and maintain benign operation of the system. However, due to the highly professionalness of medical treatment, heterogenicity and demand elasticity of medical service, and high asymmetry of medical information, the behavior of moral hazard in social medical insurance is easily concealed. Moreover, the third-party paying way of medical insurance, a design defect of the system itself, makes both medical staffs and patients obtain some illegal profit. Under such circumstance, the hazard control had become a touchy problem both theoretically and practically, because of the low cost of cheating in insurance, the moral features and uncertainty of medical consumption. The classification of moral hazard of medical insurance was conducted in this paper, based on illegal medical cases discovered in medical insurance of Wuhu city in recent years. Three kinds of moral hazard were introduced in this paper from the perspective of suppliers of medical insurance, demanders of medical insurance and conspiracy of suppliers and demanders. Furthermore, various representation and features of moral hazard in medical insurance were further verified through sample cases and data analysis, with reasons of their occurrence disclosed. In general, the causes of moral hazard of medical insurance were thoroughly analyzed mainly from the perspective of theoretical bases, medical insurance system, hospitals compensation, governing factors, moral factors and cost factors, by using related theory on economics, management science and other subjects, on the basis of the author’s rich working experience on medical insurance. Finally, suggestions on preventing medical hazard in medical insurance were provided from many aspects:medical system, law and regulation, policy guidance, technology, supervision, and moral or ethics.更多还原