吴江区职工医疗保险结算方式研究

发布时间：2018-03-19 07:19

本文选题：职工医疗保险　切入点：结算方式　出处：《西北农林科技大学》2017年硕士论文　论文类型：学位论文

【摘要】：随着我国医疗的改革不断深入,医疗保险经费出现的不合理支出问题,究其原因,还是因为医疗保险制度跟不上社会经济的发展。这种滞后性带来的问题将会对参保人员的保障权益产生根本性影响,也对医疗保险制度的稳定性、可持续性提出了挑战。因此研究人员对于医疗保险制度的设计关注度正在不断提升,希望能找到医疗保险基金的控制机制改进之路,使医疗基金的使用效率得到有效的提升。在医疗保险制度的设计中医疗保险基金的问题是重中之重,而结算方式又是医疗保险基金能够良好运行的关键。结算方式作为一种制度措施,保障着参保人员的基本医保待遇、控制着医疗服务方的过度医疗行为,有效发挥医保基金的输出作用。因此对于医保基金结算方式的现状与趋势的研究,不仅能使我们最大限度提高医保基金的使用效率,更好地发挥医保基金统筹共济的作用,最终达到医疗服务需求方和供给方双方共赢的目的。而且能在政策方面帮助加强医保基金的管理,不断推进可持续发展的医疗保险制度,为新一轮医疗卫生体制改革提供理论技术支持。本文通过对已有的研究成果、相关理论概括以及国内外相关医疗保险结算方式进行对比研究,综合分析得出我国医疗保险制度改革中关于结算方式的借鉴性意见和建议:第一建立健全具有中国社会主义特色的医疗保险法律体系;第二综合运用各种医疗费用的结算方式;第三明确参保者的个人责任;第四重复发挥商业医疗保险的补充作用;第五实现政府与市场机制的有效结合。同时,通过对苏州市吴江区医疗保险制度的发展改革道路进行梳理,针对其中结算方式的变革,提出了完善吴江区职工医疗保险结算方式的对策建议:一是进一步实施医疗保险的混合型结算方式、弹性结算方式等;二是健全法律法规体系,加强保险经办机构内控机制建设;三是建立互联共享的信息网络平台,深化诚信体系建设;四是发挥社区卫生服务在医疗服务中的基础性作用。本文的研究立足于吴江区职工医疗保险的实际情况,通过笔者在吴江医疗保险经办机构多年的工作经验,并作为医疗机构执法监督者的多次实地考察结果,分析吴江区职工医疗保险结算方式的现状及其存在的问题提出完善吴江区医疗保险的对策。文章全面系统的研究了吴江区职工医疗保险的结算方式,希望能够进一步完善吴江区职工医疗保险结算方式,有助于指导吴江区社保经办机构今后的监管工作,同时为其他孜孜不倦研究职工医疗保险结算方式的学者提供一点参考资料。各国都在对医疗制度进行不断的改革与完善,为了控制持续快速增长的医疗费用,完善医疗保险控制机制,因地制宜的选择结算方式必不可少,同时这也将成为医疗保险改革的巨大助力。本论文的意义则是在于立足吴江现状,为完善吴江区职工医疗保险体系提供可行性建议,更对推进医疗保险制度改革实践具有一定的指导意义。
[Abstract]:With the deepening reform of China's health, unreasonable expenditure of medical insurance funds appears, the reason is because of the development of medical insurance system and social economy. This lag problems will safeguard the rights and interests of insured persons have a fundamental impact on the stability of the medical insurance system, also put forward. The challenge of sustainability. Therefore researchers concern for the design of the medical insurance system is rising, hopes to improve the control mechanism of the medical insurance fund to find the road, make efficient use of medical funds improve the medical insurance system. In the design of medical insurance fund problem is the priority among priorities, and settlement what is the key to the medical insurance fund operation. As a system of measures of settlement, protection of basic health care treatment of the insured, control of medical service Excessive medical care service, effectively play the role of the health insurance fund. Therefore the output status and trend for the settlement of the medical insurance fund research, so we can not only maximize the efficiency of the use of insurance funds, better play the role of co-ordinate Masonic medical insurance fund, and ultimately achieve the demand for medical services and supply the win-win purpose and can help strengthen the management of medical insurance fund in terms of policy, continue to promote the sustainable development of medical insurance system, provide theoretical and technical support for a new round of reform of the medical and health system. Based on the existing research results, comparative study related theory summary and related domestic and foreign medical insurance settlement, suggestions and advice on the settlement of the medical insurance system reform in our country comprehensive analysis: first establish a socialist Chinese The legal system of medical insurance; medical expenses settlement second comprehensive; third clear insured personal responsibility; fourth repeat to play a complementary role of the commercial medical insurance; realize the effective combination of government and market mechanism fifth. At the same time, through sorting out the road of development and reform of medical insurance system in Wujiang District of Suzhou City, according to the settlement change the way, put forward suggestions to improve the Wujiang district medical insurance settlement: a mixed settlement further implementation of medical insurance, flexible such as clearing the way; two is to improve the legal system, strengthen the construction of the internal control mechanism of insurance mechanism; three is to establish information sharing platform for the Internet network, deepening the construction of credit system; four is the basic function of community health service use in medical services. Based on the research of Wujiang district staff medical insurance The actual situation in Wujiang, the medical insurance agency for many years of work experience, and as a medical institution supervisors on-the-spot investigation results, analysis of the current situation of Wujiang medical insurance settlement and the existing problems and puts forward suggestions of perfecting Wujiang district medical insurance. The comprehensive and systematic study of the Wujiang district staff medical insurance clearing the way, hope to be able to further improve the Wujiang district staff medical insurance settlement, will help guide Wujiang district social security agencies in the supervision work, and provide references for other studies diligently medical insurance settlement scholars. Most of the countries in the medical system of continuous reform and improvement, in order to control the rapid the growth of medical costs, improve the control mechanism of medical insurance, select the settlement will not be less, At the same time, this will also become a great help for the reform of medical insurance. The significance of this paper is based on the current situation of Wujiang, which provides a feasible proposal for improving the medical insurance system of employees in Wujiang District, and has a certain guiding significance for promoting the practice of medical insurance system reform.

【学位授予单位】：西北农林科技大学
【学位级别】：硕士
【学位授予年份】：2017
【分类号】：R197.1;F842.684

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