社会医疗保险委托管理机制研究

发布时间：2018-05-05 02:22

本文选题：社会医疗保险 + 委托管理　；参考：《西南财经大学》2013年硕士论文

【摘要】：纵观国际上的社会医疗保险改革,采取政府引入“有管理的竞争”,积极推行社会医疗保险领域的公共服务外包来降低成本、提升服务成为广泛选择。国外政府大多都通过政策鼓励第三方部门参与到社会医疗保险业务中来,实行管办分离,制定法律框架,创建相应的体制机制来约束和规范第三方受托机构的竞争,营造与医疗费用支出水平相适应的质量保障体系和效率提升机制。《中共中央、国务院关于深化医药卫生体制改革的意见》明确指出,深化医药卫生体制改革的基本原则之一,是在保障公平的基础上,统筹推进效率的提高；注重发挥政府的主导作用,同时兼顾市场在资源配置中基础性作用。切实转变政府职能,强化政府在医疗卫生制度、卫生区域规划、医疗卫生资源投入、分配等医疗卫生服务中的责任,充分体现我国医疗卫生事业具有一定福利性的社会公益性特征,保障公平；与此同时,政府也不能大包大揽,必须发挥社会主义市场经济体制的基础性作用,广泛地吸引社会力量参与,特别是社会资本、民间资本的投入,建立健全公平、合理、高效的市场竞争机制,实现社会医疗资源的优化配置,提高社会医疗卫生资源的运营效率,更好的改善和服务民生,满足人们群众多样化、多层次的医疗卫生服务需求。针对目前我国的社会医疗保险体系现状,要进一步扩大社会医疗保险覆盖面、提高统筹层次、提高医疗保险待遇水平、优化异地结算支付等,同时在自愿、互利的基础上,积极发展其他多种形式的补充医疗保险和加快试点、逐步推广大病保险项目,建立健全更高水平的多层次的社会医疗保险体系。以政府的有效监管为原则、以社会医疗保险基金的安全运营为前提,积极倡导以政府购买方式扩大社会医疗保险服务供给,探索有资质的社会力量参与、举办医疗卫生机构或者经营管理部分社会医疗保险服务项目。随着覆盖城乡居民的多层次医疗保险体系的不断建立和完善,社会医疗保险的覆盖面不断扩大、参保人数将不断增加、社会医疗保险基金的筹集和医疗费用的支付规模不断扩大、社会医疗保险的管理难度亦将不断增加,势必将对创新社会医疗保险管理体制机制、提高医疗保险管理服务水平提出更高的要求。立足于中国医药卫生体制改革目标和商业健康保险的发展方向,积极探索社会医疗保险管理引入竞争机制参与社会医疗保险管理服务就显得尤为重要,并具有相当的紧迫性。本文即在上述背景下展开分析研究,旨在探讨将大病医疗互助补充保险业务委托保险公司参与管理,而在基本医疗保险项目中采取政府购买方式,同时在现有医疗卫生资源条件下如何利用已有的费用控制经验、成果和手段,在新的各方制约关系框架下,提出切实可行的差异化的方式提高委托管理水平。全文分为5章,各章节的顺序和主要内容安排如下：第一章为“导论”,简述本文选题背景、研究意义,以及研究内容、研究方法和研究思路,简要概述了本文的主要创新之处及不足方面。第二章为“社会医疗保险委托管理的理论分析”,分析了社会医疗保险委托管理在理论上可行性,主要介绍了社会福利多元化理论、公共服务市场化理论和合同外包。第三章为“国内外社会医疗保险委托管理的现实选择”,通过简要地介绍世界上主要几个国家的社会医疗保险制度及大致的改革历程,分析了美国、英国和荷兰三国在面对医疗费用支出快速增加的背景下所采取的社会医疗保险改革措施及其蕴含的政策启示。例如美国积极鼓励商业保险公司参与各项医疗保险业务的经办管理,荷兰政府将医疗保险业务全部交给保险公司经营并通过制定监管体系来规范竞争,英国政府采取“内部市场机制”来进行医疗保险改革。而我国尚未在全国范围内进行统一的社会医疗保险管理体制机制改革,但部分地方政府积极探索医疗保险制度改革。在以湛江、德阳、厦门三地为代表的探索实践中,通过引入竞争机制或者采取与第三方机构合作,为进一步深化社会医疗保险管理机制改革提供了指导意义。可以说,在社会医疗保险领域引入管理式竞争已成为全球趋势。第四章为“社会医疗保险委托管理的模式选择和具体机制设计”,为了更好利用委托经办下的各方制约框架,特别是依据我国经济发展水平和医疗卫生总支出中个人及家庭医疗卫生支出仍占较大比重的状况下,建议对大病互助补充保险业务采用了最利于医疗费用控制和能提供更好的医疗服务的委托管理模式选择,而对基本医疗保险业务的采取政府购买机制。第五章为“结论与进一步研究问题”,本章总结了前四章的研究,得出本文的研究结论,同时对社会医疗保险委托管理的进一步研究方向进行了展望。
[Abstract]:In view of the international social medical insurance reform, the government introduced the "managed competition" and actively pursued the public service outsourcing in the field of social medical insurance to reduce the cost and promote the service to be widely chosen. Most of the foreign governments have adopted the policy to encourage the third departments to participate in the social medical insurance business. In addition, the legal framework is formulated and the corresponding institutional mechanism is created to restrict and standardize the competition between the third party trustees, and to create a quality assurance system and an efficiency improvement mechanism adapted to the level of medical expense expenditure.
"The Central Committee of the Communist Party of China, the State Council's opinion on deepening the reform of the medical and health system, clearly points out that one of the basic principles of deepening the reform of the medical and health system is to promote efficiency, on the basis of ensuring fairness, to give full play to the leading role of the government, and to take into account the basic role of the market in the allocation of resources. The government should strengthen the responsibility of the government in medical and health systems, health regional planning, medical and health resources input, distribution and other medical and health services, and fully reflect the social public welfare characteristics of the welfare of China's medical and health services and the protection of fairness. At the same time, the government can not wrap up a big package and have to play the socialist market economy. The basic role of the system is to attract the participation of social forces, especially the social capital, the input of the folk capital, the establishment of a fair, reasonable and efficient market competition mechanism, the optimal allocation of social medical resources, the improvement of the operational efficiency of the social medical and health resources, the better improvement and service of the people's livelihood, and the satisfaction of the diversity of the people. According to the present situation of the social medical insurance system in China, we should further expand the coverage of social medical insurance, improve the overall level, improve the treatment level of medical insurance, optimize the settlement and payment, and actively develop other forms of complementary medical care on the basis of voluntary and mutual benefit. Insurance and speeding up the pilot, gradually popularizing the big disease insurance project, establishing and improving the higher level and multi-level social medical insurance system, taking the effective supervision of the government as the principle, taking the safe operation of the social medical insurance fund as the premise, actively advocating the expansion of the social medical insurance service by the way of government purchase, and exploring the qualified society. To participate in the work, to organize medical and health institutions or to manage some social medical insurance services.
With the continuous establishment and improvement of the multi-level medical insurance system covering urban and rural residents, the coverage of social medical insurance is expanding, the number of insured people will increase continuously, the raising of the social medical insurance fund and the scale of medical expenses will continue to expand, and the difficulty of the management of social medical insurance will continue to increase. The medical insurance management system mechanism and the improvement of the medical insurance management service level put forward higher requirements. It is particularly important to explore the social medical insurance management and participate in the social medical insurance management service based on the target of Chinese medical and health system reform and the direction of the development of commercial health insurance. It is particularly important to introduce the social medical insurance management into the social medical insurance management service. When it comes to urgency.
The purpose of this paper is to explore the analysis and study under the above background. The purpose of this study is to discuss the participation of the insurance companies in the medical mutual assistance to the insurance companies, and to take the way of government purchase in the basic medical insurance projects, and how to use the existing cost control experience, results and means under the existing medical and health resources. Under the framework of restrictive relations, this paper puts forward a practical and feasible way to improve the management level of commission. The full text is divided into 5 chapters. The order and main contents of each chapter are as follows:
The first chapter is "Introduction", which describes the background of this topic, the significance of the research, the research content, research methods and research ideas, and briefly outlines the main innovations and shortcomings of this article.
The second chapter is "the theoretical analysis of the entrustment management of social medical insurance", and analyzes the theoretical feasibility of the social medical insurance entrustment management. It mainly introduces the theory of social welfare diversification, the theory of public service marketization and contract outsourcing.
The third chapter is "the realistic choice of the social medical insurance entrustment management at home and abroad". By briefly introducing the social medical insurance system and the general reform course of the major countries in the world, the social medical insurance reform in the United States, Britain and Holland in the context of the rapid increase of medical expense expenditure is analyzed. Measures and their implications. For example, the United States actively encourages the Business insurance company to participate in the management of the medical insurance business. The government of Holland has all the medical insurance business run to the insurance company and regulate the competition through the establishment of a regulatory system. The British government adopts the "internal market mechanism" to carry out medical insurance reform. But China has not yet carried out a unified reform of the system and mechanism of social medical insurance management throughout the country, but some local governments actively explore the reform of the medical insurance system. In the exploration and practice of the three places in Zhanjiang, Deyang and Xiamen, through the introduction of the competition mechanism or the cooperation with the third party organizations, the social medicine is further deepened. It can be said that the introduction of management competition in the field of social medical insurance has become a global trend.
The fourth chapter is "the mode selection and the specific mechanism design of the entrustment management of social medical insurance". In order to make better use of the restrictive framework of the parties under the entrustment, in particular, it is suggested that the mutual assistance to large diseases should be supplemented under the condition that our country's economic development level and the medical and health expenditure of the general medical and health expenditure still account for a large proportion of the medical and health expenditure. The insurance business adopts the choice of principal management model which is most conducive to the control of medical expenses and can provide better medical services, and the government purchase mechanism for the basic medical insurance business.
The fifth chapter is "the conclusion and further research problem". This chapter summarizes the research in the first four chapters, and draws the conclusions of this paper. At the same time, it looks forward to the further research direction of the social medical insurance entrustment management.

【学位授予单位】：西南财经大学
【学位级别】：硕士
【学位授予年份】：2013
【分类号】：F842.684

【参考文献】