郑州市城乡医疗保险制度运行现状调查分析

发布时间：2018-02-27 11:32

本文关键词： 郑州市医疗保险统筹　出处：《郑州大学》2014年硕士论文　论文类型：学位论文

【摘要】：目的本文以郑州市城镇职工基本医疗保险、城镇居民基本医疗保险、新型农村合作医疗制度为对象，从经办管理、覆盖范围、筹资金额、待遇水平、医疗服务和信息系统等方面入手，研究其在运行过程中存在的体制和机制障碍，探讨郑州市统筹城乡医疗保险制度的方案，以期为深化医药卫生体制改革、建立健全医疗保险制度提供实践依据。方法在文献分析的基础上，查询郑州历年统计公报、医疗保险相关文件、统计报表、工作总结，运用比较研究法分析郑州市城镇职工基本医疗保险、城镇居民基本医疗保险及新型农村合作医疗制度在管理部门、参保对象、管理机构、筹资政策、待遇政策、服务范围、信息系统等方面的异同；采用半结构访谈法了解郑州市医疗保险制度设计、管理模式、运行情况，分析统筹城乡社会医疗保险制度的必要性和可行性；采用头脑风暴法探讨郑州市统筹城乡医疗保险制度改革措施。结果 1.研究发现，郑州市城镇职工基本医疗保险、城镇居民基本医疗保险、新型农村合作医疗在以下几个方面存在不同：管理方面，相互独立，各自为政；覆盖范围方面，医疗保险制度设计对户籍有明确限制；筹资金额方面，城镇职工基本医疗保险明显高于另外两个保险，城镇居民基本医疗保险和新型农村合作医疗的筹资金额较为接近，但在个人负担方面仍有差别；待遇水平方面，在起付标准、报销比例、最高支付限额、普通门诊、慢病种类等方面存在差异；服务范围方面，城镇职工基本医疗保险、城镇居民基本医疗保险适用相同的药品目录，相同的定点医疗机构范围和定点药店范围，但两者在结算办法方面仍有差异，新型农村合作医疗的药品目录、定点医疗机构范围、结算办法与前两者有较大差别，其医疗服务范围明显低于前两者；信息系统方面，城镇职工基本医疗保险和城镇居民基本医疗保险共享同一信息平台，新型农村合作医疗则有其独自的信息系统，自成体系。 2.郑州市现行医疗保险制度在设计和运行中存在一些弊端，亟待改革统筹。如：制度碎片化，，管理低效率，报销程序繁琐；各险种相互独立，各自为政，信息系统不统一；重复参保、重复报销、财政重复补贴等，造成资金浪费；监督制约机制缺失等。结论 1．郑州市已建立了广覆盖、多层次的医疗保障体系，城镇职工、城镇居民和广大农村居民都可以享有基本医疗保险，为进一步统筹优化奠定了基础。 2．郑州市现行的城乡二元医疗保险体系在实际运行中引发了一系列问题，统筹改革城乡医疗保险制度势在必行。 3．改革的关键是：在体制上，打破户籍制度壁垒，设立统一的管理和经办部门，建立统一的信息服务平台；在机制上，设立不同档次的筹资标准，建立缴费与报销对等的待遇机制，充分发挥市场机制作用，最终实现统筹城乡医疗保险体系的目标。
[Abstract]:Purpose. This article takes the basic medical insurance for urban workers, the basic medical insurance for urban residents and the new rural cooperative medical care system as the object, from the management, coverage, financing amount, treatment level, Starting with the medical service and information system, this paper studies the system and mechanism obstacles existing in the process of operation, and probes into the scheme of the urban and rural medical insurance system in Zhengzhou, in order to deepen the reform of the medical and health system. Establish and improve the medical insurance system to provide practical basis. Method. On the basis of literature analysis, the author inquires the Zhengzhou statistical bulletin, medical insurance related documents, statistical reports, work summary, and applies comparative research method to analyze the basic medical insurance for urban workers in Zhengzhou. The similarities and differences between the basic medical insurance of urban residents and the new rural cooperative medical system in the aspects of management department, insured object, management organization, financing policy, treatment policy, service scope, information system, etc. Using the method of semi-structure interview to understand the design, management mode and operation of medical insurance system in Zhengzhou, and analyze the necessity and feasibility of coordinating the social medical insurance system in urban and rural areas. This paper discusses the reform measures of urban and rural medical insurance system in Zhengzhou by using brainstorming method. Results. 1. It is found that the basic medical insurance for urban workers, the basic medical insurance for urban residents and the new rural cooperative medical insurance are different in the following aspects: management, independence, and coverage; The design of the medical insurance system has clear restrictions on household registration; in terms of the amount of capital raised, the basic medical insurance for urban workers is obviously higher than the other two. The amount of funding for the basic medical insurance for urban residents and the new rural cooperative medical scheme is relatively close. However, there are still differences in personal burdens; in terms of treatment level, there are differences in starting payment standards, reimbursement rates, maximum payment limits, general outpatient clinics, types of chronic diseases, and so on; in terms of service scope, basic medical insurance for urban workers and staff, The basic medical insurance for urban residents shall be subject to the same drug catalogue, the same scope of designated medical institutions and the scope of designated pharmacies, but there are still differences between the two in terms of settlement measures. There is a great difference between the settlement measures and the former two, and the scope of medical services is obviously lower than that of the former two. In the information system, the basic medical insurance for urban workers and the basic medical insurance for urban residents share the same information platform, The new rural cooperative medical system has its own information system and its own system. 2. There are some drawbacks in the design and operation of the current medical insurance system in Zhengzhou, such as fragmentation of the system, low efficiency of management, complicated reimbursement procedures, independence of each type of insurance, and disunity of information system. Repeated participation in insurance, repeated reimbursement, repeated financial subsidies, etc., resulting in waste of funds; lack of supervision and control mechanism. Conclusion. 1. Zhengzhou has established a medical security system with wide coverage and multi-level coverage. Urban workers, urban residents and rural residents can enjoy basic medical insurance, which has laid the foundation for further overall planning and optimization. 2. The current urban-rural dual medical insurance system in Zhengzhou has caused a series of problems in the actual operation, so it is imperative to reform the urban-rural medical insurance system as a whole. 3. The key to the reform is to break down the barriers to the household registration system, to establish a unified management and administrative department, and to establish a unified information service platform. Establishing the equal treatment mechanism of payment and reimbursement, giving full play to the role of market mechanism, and finally realizing the goal of coordinating urban and rural medical insurance system.
【学位授予单位】：郑州大学
【学位级别】：硕士
【学位授予年份】：2014
【分类号】：F842.684;R197.1

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