A市城镇职工基本医疗保险基金风险控制研究

发布时间：2019-03-01 17:21

【摘要】：基本医疗保险制度是社会保障体系的重要组成部分。基本医疗保险基金是否安全运行,不仅与广大参保人员的切身利益相关,还涉及医疗保险制度是否能够可持续发展的问题。然而,医保惠民政策的不断深入、医疗费用的连年增长、我国老龄化进程的不断加剧等因素,都使医疗保险基金支出趋于无限性。医疗保险费收入的有限性和医疗保险基金支出的无限性形成的矛盾,严重危及到医疗保险基金收支平衡。目前,全国各地均存在不同程度的医保基金收不抵支的情况。对医疗保险基金风险的分析和控制就成了当前各地医疗保险经办机构的迫切任务。A市2001年开始实施职工医保制度,随着参保规模的逐渐扩大参保人员结构正趋于老龄化、选择性参保现象严重、次均统筹基金支出逐年递增、医疗保险定点单位违规行为越来越普遍,2012年往年累计的基金已经不足以承受当年的支出。本文结合风险管理理论,按照风险识别、风险评估、风险控制的流程,对A市职工医保基金进行风险控制研究。首先,按照社会保障风险的分类,把医疗保险基金风险分为内部和外部两大风险。再以A市2009年-2012年职工医保基金运行数据为基础,运用定量和定性相结合的分析方法,对A市医疗保险基金收支结余情况、参保人员结构、参保任务完成情况、医疗保险统筹基金次均支出情况、定点单位违规行为查处情况等要害数据进行分析,从而评估A市职工医保基金各风险因素。最后结合目前A市职工医保基金的构成、筹集办法、支出渠道等政策规定,借鉴国内外优秀经验,针对前面识别出的风险,从约束医疗服务供需两方行为、缓解人口老龄化压力、建立医疗保险基金风险预警机制四大角度出发,提出加快推进支付方式改革、激励参保人员自觉积极参保、优化参保人员结构、引入医疗保险精算模型等具体切实可行的风险控制措施,给A市职工医保基金的管理和风险控制提供一些可参考意见,具有实践意义。本文的创新点是：从A市职工医保的微观运行数据出发,结合国内外对医保基金风险的定性分析,有针对性地提出符合A市实际情况的风险控制措施,对A市职工医保基金的安全平稳运行具有实践指导意义。
[Abstract]:The basic medical insurance system is an important part of the social security system. The safe operation of the basic medical insurance fund is not only related to the vital interests of the general insurance personnel, but also related to the sustainable development of the medical insurance system. However, medical insurance fund expenditure tends to be limitless because of the continuous deepening of medical insurance policy, the continuous increase of medical expenses, and the aggravation of aging process in our country. The contradiction between the limitation of medical insurance premium income and the infinity of medical insurance fund expenditure seriously endangers the balance of income and expenditure of medical insurance fund. At present, there are different levels of medical insurance funds across the country. The analysis and control of the medical insurance fund risk has become the urgent task of the medical insurance agencies all over the world. A City began to implement the health insurance system for workers in 2001, with the gradual expansion of the insurance scale, the structure of the insured personnel is tending to aging. The selective insurance participation phenomenon is serious, the average fund expenditure increases year by year, the violation behavior of the fixed-point units of medical insurance is more and more common, the accumulated fund in 2012 is not enough to bear the expenditure of that year. Based on the theory of risk management and according to the process of risk identification, risk assessment and risk control, this paper studies the risk control of employee health insurance fund in A city. Firstly, according to the classification of social security risk, the medical insurance fund risk is divided into internal and external risks. Then based on the operational data of the employees' Medical Insurance Fund from 2009 to 2012 in City A, using the quantitative and qualitative analysis methods, this paper analyzes the balance of income and expenditure of the Medical Insurance Fund in City A, the structure of the insured personnel, and the completion of the task of participating in the insurance. In order to evaluate the risk factors of medical insurance fund in A city, the key data, such as the average expenditure of medical insurance fund and the investigation of illegal behavior of designated units, are analyzed in order to evaluate the risk factors of medical insurance fund in A city. Finally, combined with the current A city staff health insurance fund composition, raising methods, expenditure channels and other policy provisions, drawing lessons from excellent experience at home and abroad, aiming at the risks identified in front, from restricting the behavior of both sides of medical service supply and demand, From the four angles of alleviating the pressure of aging population and establishing a risk warning mechanism for medical insurance funds, the author proposes to accelerate the reform of payment methods, encourage participants to actively participate in insurance, and optimize the structure of insurance personnel. It is of practical significance to introduce specific and feasible risk control measures such as actuarial model of medical insurance to provide some suggestions for the management and risk control of medical insurance fund for workers in A city. The innovation of this paper is: starting from the microcosmic operation data of medical insurance for workers in A city, combining with the qualitative analysis of the risks of medical insurance fund at home and abroad, this paper puts forward the risk control measures in accordance with the actual situation of A city. It is of practical significance to the safe and stable operation of the health insurance fund for workers in A city.
【学位授予单位】：福州大学
【学位级别】：硕士
【学位授予年份】：2014
【分类号】：F842.684;R197.1

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