我国社会医疗保险委托经办管理研究
发布时间：2018-08-16 13:31
【摘要】：国外对社会医疗保险委托经办管理研究已经有很长一段时间,像美国、德国、英国等国家已经形成了各自发展模式。研究表明,在社会医疗保险中引入委托管理可以提高其运行效率、节省成本等。我国很多地区也在进行社会医疗保险委托经办管理的实践,而且取得了一定的成绩,但是也存在许多问题,例如,缺少理论支持、运行机制不成熟等。针对这些问题,笔者将详细阐述社会医疗保险发达国家的做法,总结其经验教训,然后系统阐述我国社会医疗保险委托经办管理的实践情况,研究其存在的问题,并提出可行性建议。本文具体研究思路和逻辑结构如下： 第一章,绪论部分。笔者首先阐述了本文的研究背景、意义、目的、内容和方法,综述了社会医疗保险委托管理的理论基础以及国内外有关社保委托管理的文献,并指出了本文的贡献以及不足之处。 第二章是社会医疗保险委托经办管理的国际经验及启示。社会医疗保险的发展是一个过程,在很多国外社会医疗保险发达的国家中,它们针对自己的国情采取了各种措施来解决社会医疗保险中存在的问题。例如在美国,通过把商业保险机构引入到社会医疗保障体系中,形成了一种行之有效的“管理式医疗模式”,把第三方管理引入到社会医疗保险管理中；在德国,政府部门与社会团体加强对医疗保险运行的监管,通过“管办分离”和“第三方付费”的方式来提高社会医疗保险效率,这本质上是把第三方引入到社会医疗保险服务中,这取得了很大的成效；荷兰的HIA模式也是社会医疗保险改革成功的成果,荷兰政府鼓励多家商业保险公司参与社会医疗保险产品的开发和销售,投保人可以根据自己的情况选择所要投的保险公司,竞争是荷兰HIA的核心思想,荷兰的社会医疗保险的委托经办管理主要形式也是实行“有管理的竞争”模式；最后,在英国社会医疗保险体制改革中,政府部门把市场竞争和“内部市场化改革”引入到NHS体系,以社保基金为中介来优化委托经办管理,其改革也是成功的。这些国家的改革各有各的特点,但它们的改革都有一个共同点,那就是,把市场竞争机制和委托经办管理模式引入到社会医疗保险体系中。 第三章,我国社会医疗保险委托经办管理模式及总结。我国社会医疗体制改革始于1994年,经过近20年的变革,我国社保体制取得了明显的进步。在社会医疗保险委托经办模式上,我国很多地方根据自身情况,敢于创新、大胆变革,逐步形成了一些独具特色的社会医疗保险模式。主要有：“基于大病补充医疗式的,把大病补充业务委托给商业保险公司经营”的厦门模式；“政府出资购买中介服务,保险公司负责新农合业务管理”的“江阴模式”和“新乡模式”；“把基本医疗保险和补充医疗保险全面委托给商业保险公司管理”的“湛江模式”等。这些模式的委托管理形式多样,但是总体来说,他们属于两种模式,一种是“基金管理型模式”,保险公司只收取一定保费,不承担风险；另一种是有保险公司介入的,保险公司以合同的形式参与医疗保险经营的模式,保险公司自主经营,自负盈亏,这种模式被称为“保险合同型模式”。这些模式效果显著,例如,社保参保率大幅提升、降低了社保运营成本、提高了办事效率、有利于对社保活动的监管以及促进商业保险公司发展等。 第四章,我国社会医疗保险委托经办管理存在的问题及未来发展建议。虽然我国发展出“基金管理型模式”和“保险合同型模式”两种社会医疗保险委托经办模式,但是,这两种模式发展还处于初步阶段,存在不少缺陷。本章主要研究这两种模式存在的问题及未来发展建议。首先是“基金管理型模式”,其存在的主要问题有：缺乏市场竞争,市场竞争主体少；社保基金规模小,社保资源没有得到优化配置；对社保基金运营管理缺乏监管机制。其未来发展建议有：1、实行“有管理的竞争”,在鼓励竞争的同时,进行适度的管理,让一些优质的中小保险公司也能够参与到社会医疗保险的管理中。2、放开社保业务给商业保险公司管理。3、扩大委托管理试点,加大成功经验的推广。4、加快社保委托管理专门性规范文件的制定,无规矩不成方圆,如果不建立我国社会医疗保险委托管理的规范性文件,我国在这方面的改革可能会走向“无政府”状态。其次是“保险合同型模式”,其存在主要问题有：商业保险公司参与度低；政府角色不明确,政策稳定性低；缺乏竞争性的社保基金主体。其未来发展建议有：1、鼓励商业保险公司开发医疗保障产品,从国际经验看,在社会医疗保险基金管理主体之间引入竞争机制已经取得了显著成效。2、加强对商业保险公司经办社保业务的监管,加强对商业保险公司经办业务的监管除了依靠政府强有力的行政权之外,还需要制定经办业务的相关法律,加强商业保险公司行业内的相互监管,而且媒体监督也是一个重要方面。3、明确政府定位,鼓励商业保险公司参与管理。 本文的贡献主要有：1、本文系统归纳了美国、德国、荷兰以及英国的社会医疗保险委托经办管理的经验,对这几个国家发展模式进行了比较、分析。2、本文详细阐述了厦门、新乡、江阴以及湛江四地的社会医疗保险委托经办模式,并把它们归于“基金管理型”和“保险合同型”两种模式。3、最后,笔者总结了我国社会医疗保险委托管理取得的成就、分析其存在的问题,并提出了一些未来发展建议。 本文的不足之处有：1、由于时间和能力有限,在国内外社会医疗保险模式分析时,没能做出很好的总结和分析。2、由于数据获取难度比较大,研究所需的很多数据都没有收集到,这影响了文章的实证性。3、笔者没有实地了解国内外社保委托经办管理情况,实践经验匮乏,文章所提出的几个观点和建议显得苍白无力,尚需经历时间的历练和实践的考验。
[Abstract]:It has been a long time for foreign countries to study the entrusted management of social medical insurance, such as the United States, Germany, the United Kingdom and other countries have formed their own development model. In view of these problems, the author will elaborate the practices of developed countries in social medical insurance, summarize their experiences and lessons, and then systematically expound the entrusted management of social medical insurance in China. Practice, study the existing problems and put forward feasible suggestions. The specific research ideas and logical structure are as follows:
The first chapter, the introduction part, the author first elaborated the research background, significance, purpose, content and method of this paper, summarized the theoretical basis of social medical insurance entrusted management and domestic and foreign literature on social security entrusted management, and pointed out the contribution and shortcomings of this paper.
The second chapter is the international experience and Enlightenment of the entrusted management of social medical insurance. The development of social medical insurance is a process. In many developed countries, they have taken various measures to solve the problems of social medical insurance according to their own national conditions. Institutions have been introduced into the social medical security system, forming an effective "managerial medical model" to introduce the third-party management into the management of social medical insurance; in Germany, government departments and social organizations have strengthened the supervision of the operation of medical insurance, through the "separation of management and management" and "third-party payment" to improve. The efficiency of social medical insurance is essentially the introduction of the third party into social medical insurance services, which has achieved great results; the Dutch HIA model is also the success of social medical insurance reform results, the Dutch government encourages a number of commercial insurance companies to participate in the development and marketing of social medical insurance products, the insured can according to their own. Competition is the core idea of the Netherlands HIA, and the principal form of the management of the social medical insurance in the Netherlands is the "managed competition" model. Finally, in the reform of the British social medical insurance system, the government introduced the market competition and the "internal market reform" into the N. The reform of HS system, which uses social security fund as the intermediary to optimize entrusted management, is also successful. The reforms in these countries have their own characteristics, but their reforms have one thing in common, that is, introducing market competition mechanism and entrusted management mode into the social medical insurance system.
The third chapter is the management model and summary of the entrusted management of social medical insurance in China.The reform of social medical system in China began in 1994.After nearly 20 years of reform, the social security system in China has made remarkable progress.In the mode of entrusted management of social medical insurance, many places in China dare to innovate and change boldly according to their own conditions, and gradually take shape. There are some unique social medical insurance models, such as the Xiamen model of "entrusting the supplementary business of serious illness to commercial insurance companies based on the supplementary medical treatment of serious illness"; the Jiangyin model and the Xinxiang model of "government-funded purchase of intermediary services, insurance companies responsible for the management of the new rural cooperative medical service"; and the "Ba" The Zhanjiang mode of entrusting basic medical insurance and supplementary medical insurance to commercial insurance company is various, but generally speaking, they belong to two modes: one is fund management mode, the insurance company only charges a certain premium and does not take risks; the other is insured. Insurance companies intervene, insurance companies participate in the form of contracts in the medical insurance business model, insurance companies operate independently, self-responsibility for profits and losses, this model is known as the "insurance contract model." These models have significant effects, for example, the participation rate of social security substantially increased, reduced the cost of social security operations, improved efficiency, conducive to social security. Supervision of activities and promotion of Business insurance company development.
Chapter Four, the problems and future development suggestions of the entrusted management of social medical insurance in China. Although China has developed two modes of entrusted management of social medical insurance: fund management mode and insurance contract mode, the development of these two modes is still in the initial stage and there are many defects. The first is the "fund management model", the main problems are: lack of market competition, less market competition; small-scale social security funds, social security resources have not been optimized allocation; lack of regulatory mechanisms for the operation and management of social security funds. Implement "managed competition" while encouraging competition, carry out appropriate management, so that some high-quality small and medium-sized insurance companies can also participate in the management of social medical insurance. 2. Open up the social security business to commercial insurance companies management. 3. Expand the entrusted management pilot, increase the promotion of successful experience. 4. Speed up the social security entrusted management of special. If we don't set up the normative document of social medical insurance entrusted management, our country's reform in this respect may go to the state of anarchy. Its future development suggestions are as follows: 1. Encouraging commercial insurance companies to develop medical insurance products. From the international experience, the introduction of competition mechanism among the management subjects of social medical insurance funds has achieved remarkable results. In addition to relying on the powerful administrative power of the government, it is also necessary to enact relevant laws and strengthen the mutual supervision of commercial insurance companies. Media supervision is also an important aspect. 3. Clear government position and encourage commercial insurance companies to participate in management.
The main contributions of this paper are as follows: 1. This paper systematically summarizes the experience of social medical insurance commission management in the United States, Germany, the Netherlands and the United Kingdom, compares and analyzes the development models of these countries. 2. This paper elaborates the commission management models of social medical insurance in Xiamen, Xinxiang, Jiangyin and Zhanjiang in detail, and puts them into practice. Finally, the author summarizes the achievements of the entrusted management of social medical insurance in China, analyzes the existing problems and puts forward some suggestions for future development.
The inadequacies of this paper are as follows: 1, due to the limited time and ability, in the analysis of social medical insurance model at home and abroad, did not make a good summary and analysis. 2, due to the difficulty of data acquisition, a lot of research data are not collected, which affects the empirical of the article. 3, the author did not know the domestic and foreign social security commissions on the spot. The management of the Commission Office is lack of practical experience. The opinions and suggestions put forward in this paper are pale and weak, and still need to go through the test of time and practice.
【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】：F842.3
本文编号：2186131
[Abstract]:It has been a long time for foreign countries to study the entrusted management of social medical insurance, such as the United States, Germany, the United Kingdom and other countries have formed their own development model. In view of these problems, the author will elaborate the practices of developed countries in social medical insurance, summarize their experiences and lessons, and then systematically expound the entrusted management of social medical insurance in China. Practice, study the existing problems and put forward feasible suggestions. The specific research ideas and logical structure are as follows:
The first chapter, the introduction part, the author first elaborated the research background, significance, purpose, content and method of this paper, summarized the theoretical basis of social medical insurance entrusted management and domestic and foreign literature on social security entrusted management, and pointed out the contribution and shortcomings of this paper.
The second chapter is the international experience and Enlightenment of the entrusted management of social medical insurance. The development of social medical insurance is a process. In many developed countries, they have taken various measures to solve the problems of social medical insurance according to their own national conditions. Institutions have been introduced into the social medical security system, forming an effective "managerial medical model" to introduce the third-party management into the management of social medical insurance; in Germany, government departments and social organizations have strengthened the supervision of the operation of medical insurance, through the "separation of management and management" and "third-party payment" to improve. The efficiency of social medical insurance is essentially the introduction of the third party into social medical insurance services, which has achieved great results; the Dutch HIA model is also the success of social medical insurance reform results, the Dutch government encourages a number of commercial insurance companies to participate in the development and marketing of social medical insurance products, the insured can according to their own. Competition is the core idea of the Netherlands HIA, and the principal form of the management of the social medical insurance in the Netherlands is the "managed competition" model. Finally, in the reform of the British social medical insurance system, the government introduced the market competition and the "internal market reform" into the N. The reform of HS system, which uses social security fund as the intermediary to optimize entrusted management, is also successful. The reforms in these countries have their own characteristics, but their reforms have one thing in common, that is, introducing market competition mechanism and entrusted management mode into the social medical insurance system.
The third chapter is the management model and summary of the entrusted management of social medical insurance in China.The reform of social medical system in China began in 1994.After nearly 20 years of reform, the social security system in China has made remarkable progress.In the mode of entrusted management of social medical insurance, many places in China dare to innovate and change boldly according to their own conditions, and gradually take shape. There are some unique social medical insurance models, such as the Xiamen model of "entrusting the supplementary business of serious illness to commercial insurance companies based on the supplementary medical treatment of serious illness"; the Jiangyin model and the Xinxiang model of "government-funded purchase of intermediary services, insurance companies responsible for the management of the new rural cooperative medical service"; and the "Ba" The Zhanjiang mode of entrusting basic medical insurance and supplementary medical insurance to commercial insurance company is various, but generally speaking, they belong to two modes: one is fund management mode, the insurance company only charges a certain premium and does not take risks; the other is insured. Insurance companies intervene, insurance companies participate in the form of contracts in the medical insurance business model, insurance companies operate independently, self-responsibility for profits and losses, this model is known as the "insurance contract model." These models have significant effects, for example, the participation rate of social security substantially increased, reduced the cost of social security operations, improved efficiency, conducive to social security. Supervision of activities and promotion of Business insurance company development.
Chapter Four, the problems and future development suggestions of the entrusted management of social medical insurance in China. Although China has developed two modes of entrusted management of social medical insurance: fund management mode and insurance contract mode, the development of these two modes is still in the initial stage and there are many defects. The first is the "fund management model", the main problems are: lack of market competition, less market competition; small-scale social security funds, social security resources have not been optimized allocation; lack of regulatory mechanisms for the operation and management of social security funds. Implement "managed competition" while encouraging competition, carry out appropriate management, so that some high-quality small and medium-sized insurance companies can also participate in the management of social medical insurance. 2. Open up the social security business to commercial insurance companies management. 3. Expand the entrusted management pilot, increase the promotion of successful experience. 4. Speed up the social security entrusted management of special. If we don't set up the normative document of social medical insurance entrusted management, our country's reform in this respect may go to the state of anarchy. Its future development suggestions are as follows: 1. Encouraging commercial insurance companies to develop medical insurance products. From the international experience, the introduction of competition mechanism among the management subjects of social medical insurance funds has achieved remarkable results. In addition to relying on the powerful administrative power of the government, it is also necessary to enact relevant laws and strengthen the mutual supervision of commercial insurance companies. Media supervision is also an important aspect. 3. Clear government position and encourage commercial insurance companies to participate in management.
The main contributions of this paper are as follows: 1. This paper systematically summarizes the experience of social medical insurance commission management in the United States, Germany, the Netherlands and the United Kingdom, compares and analyzes the development models of these countries. 2. This paper elaborates the commission management models of social medical insurance in Xiamen, Xinxiang, Jiangyin and Zhanjiang in detail, and puts them into practice. Finally, the author summarizes the achievements of the entrusted management of social medical insurance in China, analyzes the existing problems and puts forward some suggestions for future development.
The inadequacies of this paper are as follows: 1, due to the limited time and ability, in the analysis of social medical insurance model at home and abroad, did not make a good summary and analysis. 2, due to the difficulty of data acquisition, a lot of research data are not collected, which affects the empirical of the article. 3, the author did not know the domestic and foreign social security commissions on the spot. The management of the Commission Office is lack of practical experience. The opinions and suggestions put forward in this paper are pale and weak, and still need to go through the test of time and practice.
【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】：F842.3
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