精准化医保视角下过度医疗问题研究

发布时间：2018-04-03 14:21

本文选题：基本医疗保险　切入点：过度医疗　出处：《郑州大学》2017年硕士论文

【摘要】：基本医疗保险制度作为社会保障制度的核心部分,主要在降低参保者医疗费用方面发挥巨大作用。随着“十二五”期间我国基本建立起了覆盖全民的社会医疗保险制度(以下简称医保),医保的主要任务已经不再是提高医保覆盖率和保障水平,而转变为解决医保公平性不足和成本控制力不足的问题。因此如何提高医保的公平性和医保效率也成为现阶段研究的主要方向。通过实际的调查发现,医疗费用的不断增长会不同程度地影响医保的实施效果,使得医保的实际报销比远低于制度内报销比。而促使这一现象产生的重要因素就是过度医疗的存在。因此解决过度医疗问题,成为解决医保问题的重要突破口。文章通过对大量医疗费用和患者基本信息的数据分析,描述了过度医疗问题的现状及造成过度医疗行为的主要原因。在对过度医疗现状进行数据分析时,特别加入了健康水平指标,将健康水平作为衡量医疗行为过度的标准。调查显示,10年间省级医院医疗费用增长了7倍,但治疗效果却变化不大,这表明过度医疗的问题已经是客观存在急需解决的问题了。同时根据影响因素分析指出影响过度医疗的主要因素是患者的收入水平、医疗水平的差距和药品、诊疗的过度使用。而医保引导机制和监督机制的缺失也使得过度医疗问题难以解决。通过对过度医疗的现状和原因的分析,最终指出了过度问题还需精准解决。最后本文引入精准化医保的角度提出了解决过度医疗问题的政策建议。目前在解决过度医疗问题的策略上主要采用总量控制、改革支付方式、经济补偿、制度监控等方式,而在过度医疗行为过程中的监控研究则不成系统。因此,从精准化角度考虑如何解决过度医疗问题则是一条新的道路。“精准化”方法是国家倡导的解决方法,是针对细节,针对个体的解决方法。过度医疗的个体化、多样性和广泛性要求“精准化”的“靶向治疗”。本文提出将保障水平按病种的分类和严重程度划分档次,以提高参保者面对高额医疗费用的承担能力。加入精准化监控指标,包括住院监控指标、药品监控指标及诊疗监控指标,做到医保对医疗行为的事前、事中和事后的精细监控,以减少过度医疗的行为。同时建立独立的医保定价和报销系统,将医疗费用的增长控制在源头,以更高的体现医保的公平性、合理性和有效性。
[Abstract]:As the core part of the social security system, the basic medical insurance system plays an important role in reducing the medical cost of the insured.With the basic establishment of a social medical insurance system covering all the people during the 12th Five-Year Plan period (hereinafter referred to as Medicare), the main task of medical insurance is no longer to improve the coverage of medical insurance and the level of security.To solve the problem of insufficient fairness and cost control of health care.Therefore, how to improve the fairness and efficiency of health insurance has become the main research direction.Through the actual investigation, it is found that the continuous increase of medical expenses will affect the implementation effect of medical insurance to varying degrees, making the actual reimbursement ratio of medical insurance much lower than the reimbursement ratio within the system.Therefore, solving the problem of excessive medical care has become an important breakthrough to solve the problem of medical insurance.By analyzing the data of a large amount of medical expenses and patients' basic information, this paper describes the current situation of medical overtreatment and the main causes of overmedical behavior.In the data analysis of the status quo of excessive medical treatment, the index of health level is added especially, and the health level is regarded as the standard to measure the excessive medical behavior.The investigation shows that the medical expenses of provincial hospitals have increased sevenfold in the past 10 years, but the effect of treatment has not changed much, which indicates that the problem of excessive medical treatment is an objective problem that needs to be solved.And the lack of medical insurance guidance mechanism and supervision mechanism also makes the problem of excessive medical care difficult to solve.Through the analysis of the status quo and causes of over-treatment, it is pointed out that the problem of overtreatment needs to be solved accurately.Finally, this paper proposes some policy suggestions to solve the problem of excessive medical care from the point of view of precision medical insurance.At present, the strategy of solving the problem of excessive medical treatment mainly adopts the methods of total amount control, reform of payment method, economic compensation, system monitoring and so on, but the monitoring research in the process of excessive medical treatment is not systematic.Therefore, it is a new way to consider how to solve the problem of excessive medical treatment from the perspective of precision.Precision is the solution advocated by the state. It is a solution for details and individuals.The individualization, diversity and extensiveness of over-treatment require "targeted therapy" with precision.This paper proposes to classify the level of insurance according to the classification and severity of the disease in order to improve the affordability of the insured in the face of high medical expenses.The precision monitoring index, including hospitalization monitoring index, drug monitoring index and diagnosis and treatment monitoring index, is added to ensure the careful monitoring of medical behavior before, during and after medical care, so as to reduce excessive medical behavior.At the same time, an independent medical insurance pricing and reimbursement system is established to control the growth of medical expenses at the source, so as to better reflect the fairness, rationality and effectiveness of medical insurance.
【学位授予单位】：郑州大学
【学位级别】：硕士
【学位授予年份】：2017
【分类号】：R197.1;F842.684

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