基于“疾病划分”模式的大病医保费率研究

发布时间：2018-04-13 08:52

本文选题：大病医保 + “疾病划分”模式　；参考：《华东师范大学》2013年硕士论文

【摘要】：我国目前主要通过实施城镇职工补充医疗保险制度、城镇居民基本医疗保险制度、新型农村合作医疗制度以及大病医疗救助制度实行对大病医疗的保障。然而大病的补偿率仍然较低,重特大疾病的高额医疗费用给广大群众尤其是农村居民的生产生活带来严重的负担。为进一步完善城乡居民的医疗保险制度,大病医保应运而生。大病医保是对城镇居民以及新农合参保人补偿后个人费用的二次补偿,根据保险责任上的差异可分为“疾病划分”模式和“费用”模式两种。本文主要对“疾病划分”模式下的大病医保进行研究,为大病医保中疾病的选取、实际发病率的计算以及净保费的预测提供定量测量方法与理论思路。本文首先阐述大病医保在我国的发展,并根据国外大病保障制度提出对我国大病医保的启示。接着介绍了多层线性模型及其在大病医保研究中的适用性。最后以“大病”定义出发进行实证研究依据自付金额高低选取了7种疾病并进行权重赋值。根据所选取的疾病建立二层线性模型,分析影响自付金额的因素以及疾病种类对关键因素的解释作用,并预测不同性别、年龄层的居民的人均自付金额,再结合7种疾病的实际发病率,大致测算了疾病模式大病保险的风险保费。研究表明：住院时间以及医院级别都对自付金额有比较大的正向影响作用;但是在不同的城市,疾病对自付费用影响因素的解释作用却不一样。疾病数量以及疾病种类的不同,地区人群的差异、补偿比例的差异,合理必须常规医疗费用的限制或者突破、微利的边界、以及历史经验数据都会对大病保险的费率厘定产生影响。因此商业保险机构承保“疾病模式”大病医保时必须因地制宜的做出相应的调整,合理控制承保风险。
[Abstract]:At present, the system of supplementary medical insurance for urban staff and workers, the basic medical insurance system for urban residents, the new rural cooperative medical system and the medical aid system for serious illness are mainly implemented in China.However, the compensation rate of the serious illness is still low, and the high medical expenses of the serious and serious diseases bring a serious burden to the masses, especially the rural residents.In order to further improve the medical insurance system for urban and rural residents, health insurance emerged as the times require.Medical insurance for serious illness is a kind of secondary compensation for personal expenses after compensation to urban residents and the new rural cooperative insured. According to the difference in insurance liability, it can be divided into two types: "disease division" model and "expense" mode.This paper mainly studies the medical insurance of serious illness under the model of "disease division", which provides a quantitative measurement method and theoretical thinking for the selection of disease, the calculation of actual incidence rate and the prediction of net insurance premium.This paper first expounds the development of medical insurance for serious illness in our country, and puts forward the enlightenment to the medical insurance of serious illness in our country according to the safeguard system of serious illness abroad.Then it introduces the multilayer linear model and its applicability in the study of medical insurance for serious illness.Finally, based on the definition of "serious illness", seven diseases are selected and weighted.Based on the selected disease, a two-layer linear model was established to analyze the factors affecting the out-of-pocket amount and the explanation of the disease type to the key factors, and to predict the per-capita out-of-pocket amount of the residents of different gender and age groups.Combined with the actual incidence of 7 diseases, the risk insurance premium of the disease model is estimated.The results show that the length of stay and the level of hospital have a great positive effect on the out-of-pocket amount, but in different cities, the effect of disease on the factors of out-of-pocket expenses is not the same.The difference in the number of diseases and the types of diseases, the differences in regional population, the difference in compensation ratio, the reasonable need for the limitation or breakthrough of conventional medical expenses, and the marginal profit boundary,And historical data will have an impact on the pricing of major illness insurance.Therefore, the commercial insurance institutions must make corresponding adjustments according to local conditions and control the underwriting risk reasonably.
【学位授予单位】：华东师范大学
【学位级别】：硕士
【学位授予年份】：2013
【分类号】：F842.684;F224

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