奉化市医保付费方式存在的问题与对策研究
发布时间：2018-07-28 06:35
【摘要】：医保主要用于抵御因患病或伤害带来的医疗风险,减少因病至贫或因病返贫现象,而医保付费方式不仅保障医疗费用支出恰当合理,还可以控制医疗服务质量。随着社会发展,人们对健康需求的不断提升,过度性的医疗消费屡见不鲜,同时看病难、看病贵的情况充斥着社会,成为制约经济发展的难题。医保付费方式改革已经成为社会关注的重要话题。本文以国家提出深化医药体制改革的意见的时间为节点,运用文献分析、个案分析和统计分析三种方式方法,对奉化市医保当前的付费方式和改革前的付费方式进行对比分析,同时回顾意见提出以后的改革经过和历史沿革。奉化市当前的医保付费方式是总额预付制下,以按项目付费等为补充的混合付费方式,还建立了相关配套措施,比如家庭医生,差别化支付等。与改革前相比,奉化市医保付费方式在控费取得不错的效果,但还是存在定额指标不够科学、人为干涉过多、未能够对按病种付费引起足够重视等问题。医保付费方式改革,既要符合基本医疗保险相符合定位,还要兼顾相关者的利益,注重社会影响。结合国内外发达国家和地区普遍认为付费方式需要进一步走向精细、科学、组合化的经验,笔者对奉化市医保付费方式提出了三方面具有针对性的建议:一是要坚持完善总额预付办法,合理确定当年度预算总额,可以考虑引入谈判协商和指标调整机制;二是进一步探索混合付费方式,同时完善付费配套措施建设;三是要加强对医保基金的预算、支出、分析等工作,调整医保报销比例,避免出现基金结余过多或过少的问题。
[Abstract]:Medical insurance is mainly used to resist the medical risk caused by illness or injury, to reduce the phenomenon of illness to poverty or to return to poverty because of illness. However, the way of medical insurance payment not only ensures the proper expenditure of medical expenses, but also can control the quality of medical service. With the development of the society and the continuous improvement of people's health demand, excessive medical consumption is common, at the same time, it is difficult to see a doctor, and the expensive medical treatment is full of society, which has become a difficult problem to restrict the economic development. The reform of health insurance payment has become an important topic of social concern. Taking the time when the country put forward the suggestion of deepening the reform of the medical system as the node, using the three methods of literature analysis, case analysis and statistical analysis, this paper makes a comparative analysis of the current payment mode of medical insurance in Fenghua City and the payment method before the reform. At the same time, the review of the opinion proposed after the reform process and historical evolution. In Fenghua City, the current medical insurance payment method is a mixed payment method, which is supplemented by total prepaid system, such as item payment and so on, and has also established related supporting measures, such as family doctor, differential payment and so on. Compared with the reform before the reform, the medical insurance payment method in Fenghua City has achieved good results in controlling the fees, but there are still some problems, such as the quota index is not scientific enough, the artificial intervention is too much, and enough attention has not been paid to the payment according to the disease type. The reform of medical insurance payment not only accords with the orientation of basic medical insurance, but also pays attention to the interests of relevant parties and social impact. In combination with the experience that developed countries and regions at home and abroad generally believe that payment methods need to be further refined, scientific, and combined, The author puts forward three specific suggestions to Fenghua City: first, we should insist on perfecting the method of total prepayment, reasonably determine the total amount of budget for the current year, we can consider the mechanism of negotiation and index adjustment; Second, we should further explore the mixed payment method and improve the construction of supporting measures for payment. Third, we should strengthen the budget, expenditure and analysis of the medical insurance fund, adjust the proportion of medical insurance reimbursement, and avoid the problem of excessive or too little fund balance.
【学位授予单位】：宁波大学
【学位级别】：硕士
【学位授予年份】：2017
【分类号】：R197.1;F842.684
本文编号：2149232
[Abstract]:Medical insurance is mainly used to resist the medical risk caused by illness or injury, to reduce the phenomenon of illness to poverty or to return to poverty because of illness. However, the way of medical insurance payment not only ensures the proper expenditure of medical expenses, but also can control the quality of medical service. With the development of the society and the continuous improvement of people's health demand, excessive medical consumption is common, at the same time, it is difficult to see a doctor, and the expensive medical treatment is full of society, which has become a difficult problem to restrict the economic development. The reform of health insurance payment has become an important topic of social concern. Taking the time when the country put forward the suggestion of deepening the reform of the medical system as the node, using the three methods of literature analysis, case analysis and statistical analysis, this paper makes a comparative analysis of the current payment mode of medical insurance in Fenghua City and the payment method before the reform. At the same time, the review of the opinion proposed after the reform process and historical evolution. In Fenghua City, the current medical insurance payment method is a mixed payment method, which is supplemented by total prepaid system, such as item payment and so on, and has also established related supporting measures, such as family doctor, differential payment and so on. Compared with the reform before the reform, the medical insurance payment method in Fenghua City has achieved good results in controlling the fees, but there are still some problems, such as the quota index is not scientific enough, the artificial intervention is too much, and enough attention has not been paid to the payment according to the disease type. The reform of medical insurance payment not only accords with the orientation of basic medical insurance, but also pays attention to the interests of relevant parties and social impact. In combination with the experience that developed countries and regions at home and abroad generally believe that payment methods need to be further refined, scientific, and combined, The author puts forward three specific suggestions to Fenghua City: first, we should insist on perfecting the method of total prepayment, reasonably determine the total amount of budget for the current year, we can consider the mechanism of negotiation and index adjustment; Second, we should further explore the mixed payment method and improve the construction of supporting measures for payment. Third, we should strengthen the budget, expenditure and analysis of the medical insurance fund, adjust the proportion of medical insurance reimbursement, and avoid the problem of excessive or too little fund balance.
【学位授予单位】：宁波大学
【学位级别】：硕士
【学位授予年份】：2017
【分类号】：R197.1;F842.684
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