中美医疗保险费用支付方式比较研究

发布时间：2018-11-03 17:10

【摘要】：医疗保险是社会保障中重要的组成部分之一,它在减轻人民生活负担、提高人民生活质量和稳定社会治安方面有着突出的作用,对满足参保者医疗需求方面有着不可推卸的责任。然而现如今医疗保险出现了"看病贵,看病难"、医疗费用过快增长、参保者负担加重、政府财政基金压力大等问题,这些成为政府和人民极其关注的问题。在这个背景下医疗保险费用支付方式成为了众矢之的,政府将缓解以上问题的希望放在了改革医疗保险费用支付方式上。这些年来我们一直在努力,从按服务项目付费的后付制到现如今正在实行的预付制,从过去单一的医疗保险费用支付方式到现如今的混合型的支付方式,不难得出中国的医疗保险费用支付方式正在向更加科学更加合理的道路上前行。笔者认为在改革的道路上总结前人经验,吸取前人教训是很有必要的,因而选取了美国作为研究对象,比较了中国和美国的医疗保险费用支付方式,希望帮助到我国的医疗保险费用支付方式改革。美国是世界上医疗卫生开支最大的国家,对医疗保险费用支付方式的改革起步较早,一直在不断探索控制医疗保险费用增长的支付方式,这其中有成功也有失败,总结起来就是宝贵的经验教训。文章以中国和美国的医疗保险费用支付方式现状为切入点,应用对比分析法、文献研究法、国外借鉴法、经验总结法等方法,阐述了中国医疗保险费用支付方式的现状,和总额预付制会推诿重症患者、总额预付制将降低医疗服务质量、总额预付制标准测算出现偏差、按病种付费会转移医疗费用的问题。这些问题的成因是支付方式的监管机制不健全和很难区分合理的和不合理的费用。与此同时还介绍了美国医疗保险费用支付方式的现状、效果和改革经验,并将两国的医疗保险费用支付方式的内容、改革效果、改革进度进行了比较分析,得出美国医疗保险费用支付方式的启示,并对中国的医疗保险费用支付方式给出对策建议,建议分为两方面,一方面是关于支付方式微观影响因素的建议,一方面是关于医疗保险费用支付方式宏观影响因素的建议。关于支付方式微观影响因素的建议有:支付方式的制定要因地制宜、效仿美国管理式医疗支付方式、推进全国性的复合型支付方式、加快按病种付费向DRGs的过渡。关于支付方式宏观因素的建议有:完善各项管理措施及奖惩机制、积极引入费用支付谈判机制、科学制定总额预付制支付标准。
[Abstract]:Medical insurance is one of the important components of social security. It plays a prominent role in reducing the burden of people's life, improving the quality of life of the people and stabilizing social order. There is an unshirkable responsibility for meeting the medical needs of the insured. Nowadays, however, medical insurance has appeared such problems as "expensive to see a doctor, difficult to see a doctor", excessive increase in medical expenses, increased burden on insured persons, and heavy pressure on government financial funds. These problems have become extremely concerned by the government and the people. In this context, medical insurance payment has become a popular criticism, the government will alleviate the above problems on the reform of health insurance payment. Over the years, we've been working on everything from the post-pay-per-service system to the prepaid system that is now in place, from the past single way of paying for health insurance to the current hybrid mode of payment. It is easy to conclude that China's health insurance payment is moving towards a more scientific and rational way. The author thinks that it is necessary to sum up the previous experience and draw lessons from the former on the road of reform. Therefore, the author chooses the United States as the research object, and compares the payment methods of medical insurance costs between China and the United States. We hope to help the reform of medical insurance payment in our country. The United States, which has the largest medical and health expenditure in the world, has been exploring ways to control the growth of medical insurance costs, including success and failure. To sum up is a valuable lesson. Based on the current situation of medical insurance payment in China and the United States, this paper discusses the current situation of medical insurance payment in China by means of comparative analysis, literature research, foreign reference, experience summary and so on. The total prepaid system will degrade the quality of medical service, the standard calculation of total prepaid system will deviate, and the payment by disease will transfer the medical expenses. The causes of these problems are that the payment mechanism is not perfect and it is difficult to distinguish between reasonable and unreasonable costs. At the same time, it also introduces the current situation, effect and reform experience of the medical insurance payment method in the United States, and makes a comparative analysis of the content, the reform effect and the reform progress of the two countries' medical insurance expense payment method. This paper draws the enlightenment of the payment method of American medical insurance expenses, and gives some countermeasures and suggestions on the payment of medical insurance expenses in China. The suggestions can be divided into two aspects: one is the suggestion on the microcosmic influencing factors of the payment method, On the one hand is about the medical insurance expense payment way macroscopic influence factor's suggestion. Some suggestions on the micro influencing factors of payment methods are as follows: the formulation of payment methods should be adapted to local conditions, follow the management medical payment mode of the United States, promote the national compound payment mode, and speed up the transition from payment by disease to DRGs. Some suggestions on macro factors of payment are as follows: perfecting various management measures and mechanism of reward and punishment, actively introducing negotiation mechanism of payment of expenses, and scientifically formulating the standard of payment in advance system of total amount.
【学位授予单位】：哈尔滨商业大学
【学位级别】：硕士
【学位授予年份】：2017
【分类号】：F842.684;F847.12

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