大连市职工基本医保普通门诊统筹方案设计

发布时间：2018-02-24 17:30

本文关键词： 大连市职工普通门诊统筹方案模拟　出处：《大连理工大学》2014年硕士论文　论文类型：学位论文

【摘要】：随着医疗改革的逐渐深入,国内许多城市已经或者准备实行城镇职工基本医疗保险普通门诊统筹制度。大连市医疗保险制度的开展正面临着以下几点问题：较高的门诊费用给就诊患者带来的经济负担日益加重；三甲医院人满为患,基层机构的医疗资源却出现闲置和浪费的现象；基本医保统筹基金短缺,但个人基金账户的资金却大量沉淀,医保资金并没有得到充分的利用。鉴于以上问题,本文根据大连市实际门诊就诊情况,设计合理的普通门诊统筹支付方案,以达到抑制门诊次均费用过快增长的现象,促进大连市医疗资源的合理配置,提高医保基金的使用效率的目的。本文的研究内容主要包括以下方面：(1)概述国外的职工基本医疗保险普通门诊统筹制度,综述与分析相应的研究工作；(2)通过对目前国内门诊统筹制度实施现状的分析,结合大连市实际情况和相关的政策要求,确定大连市职工基本医保普通门诊统筹基金的筹集采用按比例划拨方式,采用不设立起付线只设置封顶线,医药费用分段按比例报销的门诊基金支付政策,门诊统筹基金按人头付费,参保职工随机选择定点机构就诊的统筹方式；(3)依据本方案设计思路,分析目前大连市职工门诊统筹基本数据,预估下一年度大连市职工门诊就诊年龄结构,门诊就诊情况、医药费用水平及门诊统筹基金的收支情况；(4)制定大连市职工基本医保门诊统筹方案,通过统计模拟和比较,评价并选择方案；(5)对大连市职工基本医疗保险普通门诊统筹制度提出建议,采用科学化的支付方式与合理的控制手段,构建有效的职工基本医疗保险普通门诊付费统筹制度。
[Abstract]:With the deepening of health care reform, Many cities in China have already implemented or intend to implement the general out-patient planning system for urban workers' basic medical insurance. The development of Dalian's medical insurance system is facing the following problems: higher outpatient expenses bring to patients. Increasing economic burden; Third Class A Hospitals are overcrowded, but the medical resources of grass-roots institutions are idle and wasteful; the basic health insurance fund is short, but the funds in the personal fund account are precipitated in large quantities. The medical insurance fund has not been fully utilized. In view of the above problems, according to the actual outpatient service in Dalian, this paper designs a reasonable general out-patient payment scheme, in order to restrain the phenomenon that the average outpatient expenses increase too fast. To promote the rational allocation of medical resources in Dalian and to improve the efficiency of medical insurance funds. The research content of this paper mainly includes the following aspects: 1) summarizing the general out-patient coordination system of foreign workers' basic medical insurance, summarizing and analyzing the corresponding research work and analyzing the current situation of the implementation of the domestic out-patient coordination system. In combination with the actual situation in Dalian and the relevant policy requirements, it is determined that the raising of the general out-patient general out-patient fund for basic medical insurance in Dalian adopts the method of proportional transfer, and the ceiling line is only set up without the establishment of the starting line. The policy of outpatient fund payment in proportion to the proportion of medical expenses, the outpatient plan fund is paid according to the head of the person, the participating staff and workers randomly select the overall way of seeing a doctor by designated organization.) according to the design idea of this scheme, By analyzing the current basic data of Dalian workers' outpatient service as a whole, and predicting the age structure and outpatient visit status of Dalian workers' outpatient service in the next year, Level of Medical expenses and income and Expenditure of the Out-patient Co-ordinating Fund. (4) to formulate an overall plan for the out-patient planning of basic medical insurance for workers in Dalian, through statistical simulation and comparison, To evaluate and select the scheme 5) to put forward suggestions on the general out-patient coordination system of basic medical insurance for workers in Dalian, and to construct an effective general out-patient payment system of basic medical insurance for workers by adopting scientific payment method and reasonable control means.
【学位授予单位】：大连理工大学
【学位级别】：硕士
【学位授予年份】：2014
【分类号】：F842.684

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