上海市医疗责任保险运行及完善对策研究

发布时间：2018-03-14 20:06

本文选题：医疗责任保险　切入点：风险管理　出处：《复旦大学》2014年硕士论文　论文类型：学位论文

【摘要】：一、研究背景随着国内医疗纠纷的发生频率越来越高,如何有效化解医疗风险,加强医疗风险管理,缓解医患矛盾已成为政府关注的重点问题。上海从2002年10月开始进行医疗责任保险的探索,并初步建立了有效的医疗风险分担机制。但是国内医疗责任保险尚处于起步阶段,发展还十分不成熟,面临较多的发展障碍和存在比较突出的问题,现行医疗责任保险在建立风险共担、激励和约束机制,构建和谐医患关系,保证医患双方合法权益中的作用未能明显体现。在此背景下,本研究对上海市医疗责任保险运行模式存在问题及完善建议进行探讨。二、研究目的和方法1、研究目的本研究拟通过访谈、调查等方法明确上海医疗责任保险的运行现状、特征和存在问题,并结合医改要求提出上海医疗责任保险的改善策略。2、研究方法在研究中,综合利用文献分析法、二手资料收集与分析、现况调查和关键知情人访谈,收集研究所需资料。通过查阅国内外有关医疗责任保险管理模式的成功经验和做法,为上海医疗责任保险模式提供借鉴；通过收集上海实行医疗责任保险10年的运行数据资料,对其发展、运行状况等情况进行统计分析；通过调查问卷和访谈,了解医院对上海医疗责任保险的认知及需求建议,如医院是否需要购买医疗责任保险,医疗责任保险的管理模式,医疗责任保险保费的合理性,对分担医疗纠纷赔偿的有效性,理赔程序,上海医疗责任保险存在问题的原因,医院对医疗责任保险的建议等。三、研究结果本次研究发现,国外的医疗责任保险主要有三种模式：商业保险为主体、依托行业或机构的互助保险、以及以国家财政保障为主体的医疗责任保险模式。三种模式的形成与发展与不同国家的卫生系统、筹资系统、文化习俗等都有关系。国内的医疗责任保险发展历史相对较短,较典型的有扩大责任范畴的北京医疗责任保险模式、强调个人责任和风险分担的深圳模式,以及强调市场竞争机制的宁波公保体模式。三者各有优缺点。上海作为国内最早探索医疗责任险的地区,当前医疗责任保险发展缓慢甚至出现倒退,表现为医院投保率下降和保险公司积极性不高等。调查发现,2011年样本中的投保率虽然高达95%,但超过一半以上的三级医院不愿投保；一、二、三级医院的年均保费介于8-44万元间；7成以上样本医院认为医疗责任保险至少能部分分担医疗事故或医疗纠纷造成的损失,但医疗责任保险的保费设置与保费调整缺乏依据；而且理赔措施繁琐,服务亟待提高,大多数三级医院在这方面的不满尤为明显(与一二级医院的差异有统计学意义)；调查对象认为,供方的市场垄断、缺乏竞争是导致服务质量较差、索赔困难的主要原因。对医疗责任保险的需求调查发现,不到1%的医院认为医疗风险应自行解决,近一半医院认为此类风险应由政府或社会协同解决,且其筹资可考虑从财政拨款中拨付。保险覆盖对象应从医院拓宽至医生个人,这可以扩大保险对象,体现大数法则和增强风险共济能力。从筹资角度,筹资水平则应该考虑与其不同专科、不同个体服务的风险挂钩。从管理模式上,近8成调查对象认为此类保险应该是非营利的,且最好由政府主导(62.4%)。研究认为当前上海市医疗责任险运行中的问题根源在于：1)从投保对象上看,以机构为主的投保对象过少,无法起到强有力的风险共济作用,这在三级医院中尤为明显：2)从保费的设置上看,保费制定和调整缺乏规范,引起保险对象的不满；3)从保险管理上看,市场机制不明确,缺乏竞争：4)从风险类型上看,忽视了医院在处理医患矛盾和医疗纠纷时的非货币成本,后续的服务没有对此类风险进行管理和分担,这可能是三级医院不愿购买保险的最主要原因之一。四、讨论与建议研究提出如下建议：1)医疗责任保险有分散医疗风险,保障医患双方合法权益,构建和谐医患关系,维护正常医疗秩序,保障医学科学健康发展的巨大作用,上海要在新一轮深化医药卫生体制改革,健全法律法规建设,保证医疗行业公益性的前提下,及时完善相关医疗责任保险制度。通过政府支持,完善相关法律法规,实行强制医疗责任保险；2)其次要科学厘定保险费率,完善医疗风险评估防范机制；3)同时要开放市场,引入竞争机制,丰富医疗责任保险产品；4)最后充分发挥第三方专业机构作用,将医疗纠纷调解与医疗责任保险有效衔接,减少医院在纠纷处理中的时间和精力投入,加强对此类非货币医疗风险的管理缓解医患矛盾,保障各方合法权益。
[Abstract]:A background with the domestic medical disputes are more frequent, how to effectively resolve the medical risk, strengthen the management of medical risk, ease the contradiction between doctors and patients has become the focus of concern of the government. To explore the start of the Shanghai medical liability insurance from October 2002, and established the effective medical risk sharing mechanism. But the domestic medical liability insurance is still in the initial stage, development is not mature yet, faced more obstacles to development and the problems existing in the establishment of medical liability insurance, risk sharing, incentive and restraint mechanisms, building a harmonious doctor-patient relationship, guarantee the legitimate rights and interests of both doctors and patients in the not obvious. Under this background, the research questions and suggestions to explore the operation mode of medical liability insurance in Shanghai city. Two, the research purpose and method of 1 research purposes in this research intends to visit Talk, investigation methods clear Shanghai operation of medical liability insurance, characteristics and existing problems, and combined with the requirements of health care reform put forward the improvement strategy of Shanghai.2 medical liability insurance, research methods in the study, the comprehensive use of literature analysis, collection and analysis of secondary data, current situation survey and key informant interviews, collect research required data. Through the successful experiences and practices at home and abroad about the medical liability insurance management mode, provide reference for Shanghai medical liability insurance model; the data operation data of 10 years of medical liability insurance through the collection of Shanghai, the development situation, the status of statistical analysis; through questionnaires and interviews, suggestions on cognition and demand Shanghai medical liability insurance to hospitals, such as hospitals need to purchase medical liability insurance, medical liability insurance management mode, medical liability insurance premiums The rationality, validity of claims, sharing medical malpractice compensation program, Shanghai medical liability insurance problems, the hospital of the medical liability insurance proposal. Three, the study found that the results of the study, medical liability insurance abroad mainly has three modes: commercial insurance as the main body, relying on industry or organization mutual insurance, as well as the national financial security as the main mode of medical liability insurance. The three modes of formation and development of different countries with the health system, financing system, are related to cultural practices. The domestic medical liability insurance development history is relatively short, the typical expanded responsibility category of Beijing medical liability insurance model, emphasis on personal responsibility and risk sharing mode of Shenzhen, and stressed that the market competition mechanism of Ningbo right mode. The three have different advantages and disadvantages. Shanghai as the earliest exploration of medical responsibility Any insurance area, the development of medical liability insurance is slow and even reverse, as the hospital insurance rate decline and the Insurance Company enthusiasm is not high. The survey found that in 2011 in the sample although the insurance rate is as high as 95%, but more than half of the three hospitals than the insured; two, three, the average annual premium level hospital between 8-44 yuan; more than 7 sample hospitals that medical liability insurance can at least share of medical malpractice or medical disputes caused by the loss, but the medical liability insurance premium and premium adjustment based on the lack of measures; and claims service needs to be improved, most complicated, three hospitals in this area is particularly obvious dissatisfaction (statistically the significance of differences and one or two grade hospitals); respondents believe, the market monopoly, lack of competition leads to poor quality of service, the main reason of medical liability claims difficult. The survey found the demand for insurance, less than 1% of the hospital that medical risk should be resolved, nearly half of the hospital that the government or society should solve such risks, and the financing can be allocated from the financial allocation. The object should be to broaden the coverage of hospital doctors, it can expand the insurance object, reflecting the law of large numbers and enhanced the risk of Masonic ability. From the financing point of view, the level of financing should be considered with different specialties, individual risk linked services. From the management model, nearly 8 of respondents believe that such insurance should be non-profit, and best led by the government (62.4%). The study believes that the current Shanghai City medical liability insurance in the operation the root of the problem: 1) from the insured object, insurance object is too small in the main body, can not play the role of Freemasonry strong risk, which is especially obvious in the hospitals of Grade Three: 2) from Paul The fee on the set, the premium formulation and adjustment of the lack of standard, cause insurance object dissatisfaction; 3) from the insurance management point of view, the market mechanism is not clear, the lack of competition: 4) from the risk type, ignoring the hospital in dealing with doctor-patient conflicts and medical disputes when non monetary costs, not on the follow-up service this kind of risk management and sharing, this may be the main reason for three hospitals to purchase insurance to one. Four, put forward the following suggestions on discussion and suggestions: 1) medical liability insurance with scattered medical risks, protect the legitimate rights and interests of both doctors and patients, to build a harmonious doctor-patient relationship, to maintain normal medical order, a huge role to guarantee the healthy development of medicine science, to Shanghai in the new round of deepening the reform of the medical and health system, improve the construction of laws and regulations, guarantee the public medical industry, improve the related medical liability insurance through the system. The support of the government, improve the relevant laws and regulations, the implementation of compulsory medical liability insurance; 2) next to the scientific premium rates, improve the medical risk assessment and prevention mechanism; 3) to open up the market, the introduction of competition mechanism, enrich the medical liability insurance products; 4) finally give full play to the role of the third party professional organizations, the medical dispute mediation and the medical liability insurance effectively, reduce the hospital in the disputes in time and effort, to strengthen the medical risk management of non monetary easing the doctor-patient conflicts, protect the legitimate rights and interests of all parties.

【学位授予单位】：复旦大学
【学位级别】：硕士
【学位授予年份】：2014
【分类号】：R197.1;F842.684

【二级参考文献】