新农合大病保险风险分析与控制

发布时间：2018-03-07 17:03

本文选题：新农合大病保险　切入点：风险识别　出处：《山东大学》2014年硕士论文　论文类型：学位论文

【摘要】：由原来的公费医疗到全民医保，我国医疗保障体系不断完善和深化。现阶段我国基本医疗保障水平比较低，特别是对重大疾病的保障存在不足。医疗费用个人负担重，因病致贫、因病返贫现象比较普遍。为了提高城乡居民医疗保障水平，2012年国家发布了《关于开展城乡居民大病保险工作的指导意见》，引入市场机制，建立大病保险制度，减轻居民的大病负担。保险公司也以社会管理者的身份参与到我国医疗卫生改革的浪潮中。城乡居民大病保险即将在全国铺开实施，通过全面识别风险因素和科学风险评估，可以让决策者了解现阶段大病保险面临的风险状况，还能为决策机关调整工作方式起指导作用，对大病保险稳健运营有重要意义。回顾以往文献资料，前人对社会医疗保险的总结和研究多集中于基金风险、管理模式等具体问题的探讨，对运营风险的全面识别和测算问题涉及较少，并且站在保险公司角度进行分析，考虑的风险因素也会有所不同。因此文章的目的在于全面识别影响保险公司运营大病保险的各项风险因素，，形成风险评价体系，并尝试用风险度量方法评价2013年试运行状态下的新农合大病保险风险状况。在新农合大病保险的时代背景和政策背景下，文章以全面风险管理理论为支撑，结合山东人保2013年新农合大病保险数据，挖掘现实工作和数据背后反映的问题，初步识别新农合大病保险存在的内部和外部风险因素。识别出的风险因素经过保险公司专业人员的修正和补充，建立了风险评价指标体系。在风险评估环节中，考虑到大病保险运行时间较短，具体的风险数据难以掌握，有效数据时间跨度短也难以做回归分析，因此本文选择运用AHP-模糊综合评价模型为风险做评估。首先用层次分析法确定指标权重，采用专家咨询法，邀请高校保险系教授、卫生部门、保险公司大病保险管理部门以及医院医保报销部门等4个单位的12名专家对风险因素进行评估。随后运用模糊综合评价测算指标风险值。评价结果通过ABC法进行分类，将指标分成了“一般风险因素”、“主要风险因素”和“重要风险因素”，结果显示大病保险存在一定风险，但尚在可控范围，各指标中“政策管理”对大病风险影响程度最大，其次为“医疗需求风险”和“运营管理风险”。“基金风险”对整体风险影响较小。风险控制方面，依据控制的基本步骤、结合测算结果，有针对性的为每个风险主体提供风险控制建议。评价结果能帮助决策者更全面认知大病保险存在的风险隐患，了解目前的风险情况，并能提供风险控制的侧重方向。只有保证基金安全、控制医疗需求、加强运营管理、科学制定大病政策，才能确保大病保险安全运行，才能让居民更大程度的享受医疗福利。
[Abstract]:From public medical treatment to universal medical insurance, the medical security system of our country has been continuously improved and deepened. At this stage, the level of basic medical security in China is relatively low, especially in the protection of major diseases. The individual burden of medical expenses is heavy. In order to improve the level of medical security for urban and rural residents, in 2012, the State issued the guidelines on carrying out serious illness Insurance for Urban and Rural residents, introducing a market mechanism and establishing a serious illness insurance system. Insurance companies also participate in the wave of health care reform as social managers. Urban and rural residents' serious illness insurance will soon be implemented throughout the country. Through comprehensive identification of risk factors and scientific risk assessment, policy makers can understand the risk situation facing serious illness insurance at this stage. It can also play a guiding role in adjusting the working methods of the policy-making organs, and has important significance for the steady operation of the insurance against serious illness. Reviewing the previous literature, the previous summary and research on social medical insurance mainly focused on fund risk, management model and other specific issues, and the overall identification and measurement of operational risks were less involved. Therefore, the purpose of this paper is to comprehensively identify the risk factors that affect the operation of the insurance company and form a risk evaluation system. The risk measurement method is used to evaluate the risk status of New Rural Cooperative Disease Insurance (NCMS) under the condition of trial operation in 2013. Under the background of the times and policies of the New Rural Cooperative Medical Insurance (NCMS), this paper, supported by the theory of comprehensive risk management, combined with the data of PICC in 2013, excavates the problems reflected in the actual work and the data. The internal and external risk factors of NCMS insurance are preliminarily identified. The identified risk factors are revised and supplemented by insurance company professionals, and a risk evaluation index system is established. Considering the short operating time of serious illness insurance, the difficulty in mastering specific risk data, and the difficulty in regression analysis for short time span of effective data, Therefore, this paper chooses the AHP- fuzzy comprehensive evaluation model to evaluate the risk. Firstly, the AHP is used to determine the index weight, and the expert consultation method is adopted to invite the professors of the insurance department of colleges and universities and the health department. The risk factors were evaluated by 12 experts from 4 units, including the insurance management department of the insurance company for serious illness and the medical insurance reimbursement department of the hospital. Then the index risk value was measured by fuzzy comprehensive evaluation. The evaluation results were classified by ABC method. The indexes are divided into "general risk factors", "main risk factors" and "important risk factors". The results show that there is a certain risk in the insurance of serious illness, but it is still under control, and "policy management" has the greatest influence on the risk of serious illness. Secondly, "Medical demand risk" and "Operation Management risk". "Fund risk" has little effect on the overall risk. In risk control, according to the basic steps of control, combined with the calculation results, Provide risk control advice for each risk subject. The evaluation results can help the decision makers to understand the hidden risks of the insurance, understand the current risk situation, and provide the direction of risk control. Only to ensure the security of the fund, control medical needs, strengthen the operation management, Only by making the serious illness policy scientifically can we ensure the safe operation of the serious illness insurance and let the residents enjoy the medical benefits to a greater extent.
【学位授予单位】：山东大学
【学位级别】：硕士
【学位授予年份】：2014
【分类号】：F323.89;F842.684;R197.1

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