【作者】 刘芳；

【导师】 张明锁；

【作者基本信息】 郑州大学 ， 公共管理， 2012， 硕士

【摘要】 随着社会医疗保险的快速发展,参保人数不断增加,医保基金规模日益扩大,城镇职工在医疗保险占相当大的比例,参保状态相对稳定,所享受待遇较高,如何做好防范城镇职工医保基金流失,已经成为一个重要社会难题。为了确保城镇医疗保险基金能够有效的发挥作用,真正的把医保基金的钱用在参保人的身上,尽可能的发挥基金的最大作用,国家也出台了一系列管理基金的办法与规定,然而,在实际的情况中,医保统筹基金被浪费,骗取、挪用甚至贪污的现象在各地不同程度的存在,严重损害医保基金的使用效果和效率。通过深入分析医疗保险的宏观政策和医疗机构的微观运行,提出防范城镇职工医疗保险基金流失的有效手段和途径。本文结合Z市医疗保险运行有关情况,从医疗保险基金收入和支出两个方面分析基金运行中存在的风险、运行风险形成的主要原因,主要来自参保单位规避、参保人员和医疗机构的道德风险、医保政策调整、高额医疗费用增长,提出应扩面增收、增强医保基金的抗风险能力；加大医保基金稽查力度和处罚力度,规避参保单位的道德风险；加强政策宣传及制定处罚措施,防范参保人员的道德风险；加快网络信息系统建设,实现高效优质的管理。同时要规范医疗行为,加快医疗机构的配套改革、进一步加强对定点医疗机构的监督和管理、探索建立医疗保险的完整体系、努力培养一支专业素质高的医疗保险检查稽核队伍、加大宣传力度、增强参保者维权意识等五个方面提出对策建议,确保医疗保险事业全面、协调、可持续发展。更多还原

【Abstract】 With the rapid development of social medical insurance, the insured population increases ceaselessly, health insurance fund dimensions expands increasingly, urban workers in the medical insurance accounts for a considerable proportion of insurance status, relatively stable, enjoy treatment high, how to do well in prevention of medical insurance for urban workers, the outflow of funds, has become an important social problem.In order to ensure the medical insurance funds can play an effective role, true to the health insurance fund for insurance money in the US, as far as possible to fund the biggest effect, countries have also introduced a series of fund management measure and regulation, however, in the actual situation of medical insurance fund, waste, fraud, embezzlement and corruption in varying degrees throughout the existence of serious damage to health insurance fund, the use effect and efficiency.Through a thorough analysis of the medical insurance policy and medical institutions of the microscopic operation,put forward to be on guard the employee medical insurance fund loss of effective means and ways.The paper analyzes the risks of medical insurance fund operation from the medical insurance fund income and expenditure,by considering some situation of medical insurance operation in Z County.The risk come mainly from insurance units evasion,moral hazard of the insurance and medical institutions,policy adjustment,and high medical costs. It suggests that we should extend coverage and increase income,boost up the Fund’s ability to resist risks,increase the intensity of fund management and penalties,avoid moral hazard of the insurance units, raise the level of medical insurance coordinate and enhance coordination capacity,strengthen policy advocacy and set penalties to prevent moral hazard insurance personnel.We also neel to improve the management and monitoring of medical insurance agencies to from an effective supervision and restraining mechanism;speed up network information system for efficient quality management。Some suggestions were proposed from accelerating the correlative reform of medical institution,strengthening the management and supervision of lisited medical institution,establishing integrity system of medical insurance,cultivating professional audit talents for medical insurance, enhancing the propaganda,enforcing the consciousness of vindicating rights and interests for insurants. In order to ensure the development of medical insurance comprehensive coordinated and sustainable.更多还原