支付方式、参保人年龄结构与医疗保险基金支付风险——以B市医保基金政策和数据为例

发布时间：2018-09-03 11:26

【摘要】：社会医疗保险必须控制医疗费用支付的风险,中国城镇职工基本医疗保险采取全国统一的模式,区分参保人住院和门诊费用,分别建立统筹账户和个人账户进行支付。在此支付方式下,为了防止个人门诊费用负担过重,该制度还设计了统筹账户转移部分费用到人账户政策和门诊部分超额费用统筹报销的模式。本文以B市2007年到2012年数据为基础,提出了按年龄分布的支付风险因子的理念和计算,发现伴随着近年来人口结构的变化,现有的基金支付方式使得医疗保险"基金支付风险"不同于"医疗费用风险"的按不同年龄的分布,不同年龄段医疗费用结合现有的支付方式使得相对年轻的"老龄"群体"医保基金支付风险"的增加,而这种"扭曲"和改变会随着中国人口老龄化整体趋势会严重影响医保基金支付的整体风险,本文根据支付方式与参保人年龄结构综合作用的风险的分布进行了分析并给出相应的政策建议。
[Abstract]:Social medical insurance must control the risk of payment of medical expenses. The basic medical insurance of urban workers in China adopts a unified national model, which distinguishes the inpatient and outpatient expenses of the insured, and establishes an overall plan account and an individual account for payment respectively. In this way of payment, in order to prevent the individual outpatient expenses from being overburdened, the system also designs the policy of transferring part of the expenses from the overall account to the human account and the mode of overall reimbursement of the excess expenses of the outpatient. Based on the data of B city from 2007 to 2012, this paper puts forward the idea and calculation of payment risk factor according to age distribution, and finds that the change of population structure is accompanied by the change of population structure in recent years. The existing method of fund payment makes medical insurance "fund payment risk" different from "medical cost risk" by age distribution. The combination of health care costs of different age groups and existing payment methods has increased the risk of health insurance fund payments in the relatively young "elderly" group. And this "distortion" and change will seriously affect the overall risk of health care fund payments as China's population ages. This paper analyzes the risk distribution of the comprehensive effect of the payment method and the age structure of the insured and gives corresponding policy recommendations.
【作者单位】：北京科技大学文法学院;清华大学公共管理学院;
【分类号】：R197.1;F842.684

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