北京市基本医保引入商保管理的可行性及策略研究

发布时间：2018-06-29 13:08

本文选题：北京 + 基本医疗保险　；参考：《中国人民解放军军事医学科学院》2013年硕士论文

【摘要】：随着新医改政策的实施,北京市也出台了一系列健全医疗保障制度的惠民政策,包括在全国率先建立了基本医保覆盖全体城乡居民的体系制度、不断提高保障待遇、开展按疾病诊断分组付费、总额预付等付费机制改革。尽管如此,面对快速上涨的医疗需求和医疗费用,惠民医保政策的可持续性引人担忧。十八大机构改革后,明确提出要整合城乡居民的医保制度。在这情况下,北京基本医保制度进一步提高城乡居民统筹层次、统一报销待遇的任务也更加艰巨。本文从情报学角度出发,一是采用文献调研方法,分析借鉴德国、英国、荷兰的国际先进医疗保障制度改革经验,梳理国外商业保险机构参与社会保险经办的做法,提出对我国完善医保制度的启示,同时对国内洛阳、湛江区引入商业保险机构参与当地基本医保经办的运行机制和取得实效进行分析,借鉴其成功经验。二是采用实地调研方法,对北京市平谷区试点商业保险经办新农合的具体措施、取得成效进行经验总结。三是采用SWOT分析法,分析我国目前主要商业保险机构参与当地基本医保经办的三种模式的优势、劣势、机遇和挑战。四是利益相关者权力与利益分析,调研对象包括市、县级管理机构人员,医疗机构相关管理人员,商业保险机构管理人员,以此得出北京市推广试点的难度和价值。五是采用专家咨询方法,对基本医保引入商业保险机构管理的理论基础、政策基础和社会经济条件等进行探讨,咨询范围涉及国内外健康保险、基本医疗保险管理、医院管理等领域的专家。进一步分析在北京市完善基本医疗保险制度工作中引入商业保险机构参与经办的条件,提出商业健康保险经办北京市基本医疗保险的政策建议,为北京市医药卫生改革工作提供依据。与上海、天津相比,北京市的医保政策较为宽松,自新医改后,保障水平不断提高,财政投入的力度逐渐加大,但仍然存在保险待遇不一致、统筹层次有待进一步提高；购买监督机制有待完善；多元支付方式改革有待深入,谈判机制尚未建立；医保的杠杆作用在有序就医、降低诊疗成本中的作用尚待发挥；医疗救助体系有待进一步完善的问题。同时,人口结构的改变、财政高投入增长模式难以持续、医疗保障支出压力持续增加、降低经办成本的行政要求对医保基金的管理提出了新的挑战。总结德国医疗保障体系(社会医疗保险模式)、英国医疗保障制度(国家医疗保险模式)、荷兰医疗保障体系(改革后的商业保险委托管理)的医保管理机制和运行模式,发现国际医疗保险的成功经验是充分发挥商业医疗保险机构的互补优势,参与社会医疗保险管理中。国内目前很多地区也已引入商业保险管理当地基本医保,主要采用洛阳模式(委托管理方式)、湛江模式(间接切入方式)和平谷模式(共保联办方式)和全额转保等几种经办模式。商保参与当地基本医保经办后,节约了行政成本、控费效果明显、提高了保障待遇、更大效率的使用了医保基金,在机制、专业性、管理、成本等方面有优势。比较商保机构参与基本医疗保险经办模式和现有经办机构扩大自身队伍来经办模式,发现：商保机构与政府主管部门由于责、权、利对称,人事制度灵活,专业化管理经办水平较高,管理效率、基金长期的安全性都相对较高。北京市商业保险发展迅速,在医疗卫生体系建设中发挥的作用已经显现,引入商业保险经办基本医疗保险的基础也已具备,下一步在北京市推广的条件已成熟,从长远发展和国际惯例来看,推进医疗保险改革,使社会医疗保险和商业医疗保险成为中国未来的医疗保险主流模式是必经的道路。比较全国主要的几种商保经办基本医保模式的优势、劣势、风险和挑战,共保联办模式在运行机制上具有更强的科学性和现实操作性,能有效克服委托管理模式和全额转保模式两种模式存在的弊端,也最能实现政府医保部门和商业保险机构的优势互补、有效结合。从预期效果上来看,既能够实现政府引入商业保险机制的预期目标,又能够兼顾商业保险机构的利益,调动商业保险机构的积极性,实现持续合作。另外,共保联办模式对政府现有经办力量也不会带来任何冲击和影响,推进改革工作阻力相对较小。结合平谷区实施的经验,提出北京市引入商业保险机构参与基本医疗保险制度应选用“共保联办”模式。对于医疗保险经办的具体实施的建议包括有步骤地推进社会医疗保险经办体制改革,走向有管理的竞争；继续扩大财政对医疗卫生投入中“补需方”的比重；多渠道完善医保购买监督机制；发展商业健康保险,促进其与社会医疗保险的合作伙伴关系,借其力降低患者就医医疗费用支出、提高患者就医满意度、引导其参与医疗服务机构、养老服务机构建设,为广大患者提供多样化医疗服务。
[Abstract]:With the implementation of the new health care reform policy, Beijing has also introduced a series of policies to improve the health care system, including the establishment of the system system of basic medical insurance covering all urban and rural residents in the country, the continuous improvement of the guarantee treatment, the payment of payment mechanism according to the disease diagnosis group, the total prepayment and so on. The sustainability of the health care policy of Huimin is worried by the rising demand for medical care and medical costs. After the reform of the eighteen major institutions, it is clear that the medical insurance system for urban and rural residents should be integrated. In this case, the basic medical insurance system in Beijing further improves the overall level of urban and rural residents, and the task of unifying the reimbursement treatment is even more arduous.
From the point of view of information science, one is to use literature research method to analyze the experience of the international advanced medical insurance system reform in Germany, Britain and Holland, to sort out the practice of foreign commercial insurance institutions to participate in social insurance, and to put forward the enlightenment to our country to perfect the medical insurance system, and to introduce commercial insurance machine to Luoyang and Zhanjiang District in China. The operation mechanism and the actual effect of the local basic medical insurance agency are analyzed, and the successful experience is used for reference. Two the concrete measures of the pilot commercial insurance for the pilot commercial insurance in Pinggu District of Beijing are summarized by the method of field investigation. The three is to use the SWOT analysis method to analyze the main commercial insurance institutions of our country. Take part in the advantages, disadvantages, opportunities and challenges of the three local basic medical insurance models. Four is the analysis of the rights and interests of the stakeholders. The research objects include the city, the staff of the county management institutions, the related management personnel of the medical institutions, and the managers of the commercial insurance institutions. In this way, the difficulty and value of the Beijing promotion pilot are obtained. Five The method of family consultation is to discuss the theoretical basis, policy basis and social and economic conditions for the introduction of basic medical insurance to the management of commercial insurance institutions. The consultation scope involves experts in the fields of health insurance at home and abroad, basic medical insurance management, hospital management and other fields. Further analyses are introduced into the basic medical insurance system in Beijing. In order to provide the basis for the medical and health reform in Beijing, the policy proposals for the commercial health insurance to run the basic medical insurance of Beijing have been put forward by the industry insurance agencies.
Compared with Shanghai and Tianjin, the medical insurance policy of Beijing is relatively loose. After the new medical reform, the level of security is increasing and the financial input is gradually increasing. However, there is still no agreement on the insurance treatment, the overall plan needs to be further improved; the purchase supervision mechanism needs to be improved; the reform of the multi payment mode needs to be further developed and the negotiation mechanism has not been built yet. The role of the leverage of medical insurance in the orderly medical treatment and reducing the cost of diagnosis and treatment remains to be played; the medical assistance system needs to be further improved. At the same time, the changes in the population structure, the high investment growth model of the public finance are difficult to continue, the pressure of medical security expenditure is continuously increased, and the administrative requirements of the cost of management are reduced to the management of the medical insurance fund. The new challenge was put forward.
The German medical insurance system (social medical insurance model), the British medical security system (the state medical insurance model), the medical insurance management mechanism and operation mode of the medical insurance system (after the reform of the commercial insurance entrustment after the reform), found that the successful experience of the international medical insurance is to give full play to the complementary advantages of the commercial medical insurance institutions. In the management of social medical insurance, many parts of the country have also introduced commercial insurance to manage the basic medical insurance in many areas at present, mainly using Luoyang model (Entrustment Management), Zhanjiang model (indirect entry mode) and Pinggu model (co insurance joint mode) and full reinsurance. It saves the administrative cost, the cost control effect is obvious, the guarantee treatment is improved, the medical insurance fund is used more efficiently, and it has advantages in the aspects of mechanism, professionalism, management and cost.
Compare the business insurance agencies to participate in the basic medical insurance management model and the existing agencies to expand their own teams to run the model. It is found that the commercial insurance agencies and the government departments are relatively high in the management level, the management efficiency and the long-term security of the fund are relatively high because of the responsibility, the right, the profit symmetry, and the management efficiency. The long-term security of the fund is relatively high. The commercial insurance of Beijing city. With the rapid development of insurance, the role played in the construction of medical and health system has already emerged. The basis of introducing commercial insurance to run basic medical insurance has also been established. The next step in Beijing is mature. From the perspective of long-term development and international practice, the reform of medical insurance has been promoted, and social medical insurance and commercial medical insurance have become the medium. The mainstream medical insurance mode in the future is a necessary road.
Comparing the advantages, disadvantages, risks and challenges of the basic medical insurance models of several major commercial insurance agencies in China, the co insurance co operation model has more scientific and practical operability on the operating mechanism, and can effectively overcome the disadvantages of the two modes of entrustment management mode and full transfer mode, and can also realize the government medical insurance department and commercial insurance most. The advantages of the institutions are complementary and effective. From the expected effect, it can not only achieve the expected goal of the government's introduction of the commercial insurance mechanism, but also give consideration to the interests of the commercial insurance institutions, mobilize the enthusiasm of the commercial insurance institutions and achieve continuous cooperation. In addition, the co insurance model will not bring any impact on the government's existing power. The resistance of the reform work is relatively small. According to the experience carried out in Pinggu District, it is suggested that the "co insurance co operation" model should be selected for the introduction of commercial insurance institutions in Beijing to participate in the basic medical insurance system.
The recommendations for the implementation of the medical insurance policy include step by step to promote the reform of the social medical insurance system and the management competition; continue to expand the proportion of the "demander" in the medical and health investment; improve the medical insurance purchase supervision mechanism by multi channels; develop the commercial health insurance and promote the social health insurance. The cooperative partnership can reduce the cost of medical treatment for patients, improve the patient's medical satisfaction, guide them to participate in the medical service institutions, the construction of old-age service institutions, and provide diversified medical services for the majority of the patients.
【学位授予单位】：中国人民解放军军事医学科学院
【学位级别】：硕士
【学位授予年份】：2013
【分类号】：F842.684

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