我国商业健康保险道德风险控制研究

发布时间：2018-01-31 04:14

本文关键词： 商业健康保险道德风险风险控制　出处：《广西大学》2014年硕士论文　论文类型：学位论文

【摘要】：随着我国市场经济的飞速发展和综合国力的不断提升,医疗卫生水平也在逐步提高。在医疗技术日益进步的同时,医疗费用也以惊人的速度增长。我国社会主义初级阶段的特征决定了我国现阶段的社会医疗保障水平还存在一定的缺陷,商业健康保险的重要性正日益凸显。目前,我国商业健康保险市场的发展还存在一定的不足：健康保险公司经营利润低,赔付高。健康保险的“第三方支付”模式存在严重缺陷,增加了医患勾结的道德风险。依赖于药价的医疗服务价格补偿机制也为健康保险道德风险的滋生推波助澜。在道德风险频发的今天,市场行为主体之间的信任缺失,正常的市场行为主体关系已被扭曲。建立一个良性运行的健康保险体系,保持商业健康保险市场主体利益行为的均衡,不仅有利于满足广大群众的医疗需求,还能更好的支持医疗体制改革,促进经济的发展和社会的稳定。本文以博弈论相关的概念、模型为依据,构造了健康保险参与人之间的博弈模型。模型结果证明,道德风险成本直接受到保险公司监管水平和监管力度的影响。增加医疗机构和被保险人因违约或欺诈而承担的风险成本,会在一定程度上减少道德风险行为,并且能够有效维护双方的合法权益。保险公司必须提高自身风险管控能力,采用多渠道、多策略的方式去加强医疗服务需求方和供给方的监管,建立利益共享的激励机制,改善健康保险公司经营状况,从根本上遏制道德风险行为的发生。本文还借鉴美国商业健康保险的成功经验,从美国商业健康保险市场发展现状入手,探索美国商业健康保险防范道德风险的新技术,深入研究了管理式医疗在遏制道德风险行为方面的有效措施。文章结合中国的具体国情,从医疗机构、被保险人、保险公司内部和医疗服务监督方四个层面深入探讨了中国商业健康保险道德风险的控制问题。通过保险公司、医疗机构、社会监督三管齐下,更好地发挥商业健康保险的重要作用。
[Abstract]:With the rapid development of China's market economy and the continuous improvement of comprehensive national strength, the level of medical and health care is also gradually improving. Medical expenses are also increasing at an alarming rate. The characteristics of the primary stage of socialism in China determine that there are still some defects in the level of social medical security at the present stage of our country. The importance of commercial health insurance is becoming increasingly prominent. At present, the development of commercial health insurance market in China still has some shortcomings: the operating profit of health insurance companies is low. The "third party payment" model of health insurance is seriously flawed. It increases the moral hazard of doctor-patient collusion. The compensation mechanism of medical service price which depends on the drug price also contributes to the development of moral hazard of health insurance. Lack of trust among market actors, the normal relationship between market actors has been distorted. Establish a healthy health insurance system to maintain the balance of commercial health insurance market interest behavior. Not only to meet the medical needs of the masses, but also to better support the reform of the medical system, promote economic development and social stability. Based on the related concepts and models of game theory, this paper constructs a game model between health insurance participants. The cost of moral hazard is directly affected by the level and intensity of supervision of insurance companies. Increasing the risk cost of medical institutions and insured due to breach of contract or fraud will reduce moral hazard behavior to a certain extent. And can effectively protect the legitimate rights and interests of both sides. Insurance companies must improve their own risk control ability, adopt multi-channel, multi-strategy way to strengthen the medical service demand-side and supply-side supervision. To establish an incentive mechanism for benefit-sharing, improve the management of health insurance companies, and fundamentally curb the occurrence of moral hazard behavior. This article also draws lessons from the successful experience of commercial health insurance in the United States. Starting with the development of American commercial health insurance market, this paper explores the new technology of American commercial health insurance against moral hazard. This paper deeply studies the effective measures of management medical treatment in curbing moral hazard behavior. The article combines with the specific conditions of China, from medical institutions, insured. This paper probes into the control of moral hazard in China's commercial health insurance from four aspects: insurance company internal and medical service supervisor. Through insurance company, medical institution and social supervision, there are three aspects: insurance company, medical institution and social supervision. Better play the important role of commercial health insurance.
【学位授予单位】：广西大学
【学位级别】：硕士
【学位授予年份】：2014
【分类号】：F842.684

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