山东省城乡居民基本医疗保险制度整合效果评价研究

发布时间：2018-05-14 20:38

本文选题：基本医疗保险制度 + 城乡居民医保整合　；参考：《山东大学》2017年硕士论文

【摘要】：研究背景建国以来,我国的居民基本医疗保险体系建立在城乡二元社会经济发展差异化的基础上,制度建设呈现出多元化、碎片化的不良特征。随着社会经济的发展,不同医疗保险制度带来的城乡间的不平等弊端日益凸显。城镇居民医保和新农合制度,分属不同的管理部门,筹资、保障水平差距大,与保障城乡居民健康权益的公平性及实现全民医保制度的目标不相适应,对于社会保障制度的持续健康发展产生了不利影响,整合城乡居民基本医疗保险制度成为经济社会发展的必然。为此,国务院和党的十八大均提出了消除城乡差别、实现城乡医保制度一体化发展的要求,2016年《国务院关于整合城乡居民基本医疗保险制度的意见》更是对各省开展城镇居民医保和新农合制度的整合工作进行了明确规定和部署。山东省于2014年开始在全省推行城乡居民医保制度的整合工作,2015年实行城乡统一的居民基本医疗保险制度,但尚未开展城乡居民医保整合效果的评估工作。为及时总结城乡居民医保整合过程中的问题,进一步完善医保整合制度,有必要对整合过程及效果进行系统评价,以保障城乡居民医保制度运行的健康和可持续性。研究意义与目的对山东省的城乡居民医保整合效果进行系统评价,意在及时总结山东省医保整合的成效和问题,为山东省城乡医保整合工作的进一步改进提供策略建议,这对居民医保制度的建设和持续发展具有重要意义。同时,通过研究构建医保整合效果的评价指标体系,能够弥补目前城乡居民医保整合系统评价研究的空缺并为其他省市开展城乡医保整合评价提供依据。本研究的主要目的是通过构建评价指标体系,系统评价山东省城乡居民医保整合各个环节的效果,明确医保整合的具体成效和问题,为进一步完善城乡居民医保整合工作提供政策建议。研究方法利用“结构-过程-结果”评价理论、德尔菲专家法、层次分析法完成评价指标体系的构建。抽取了东营、威海、淄博、临沂、济宁5个样本市进行研究,并于样本市分层随机抽取了样本医保管理经办机构、医疗机构和参保居民家庭,进行问卷调查和访谈,获取所需数据资料。依据制定的"评分细则"对样本市指标进行打分并计算评价结果。研究结果1.城乡居民医保整合效果评价指标体系构建结果:研究确立了由“制度建设情况”、“制度落实情况”、“制度实施效果” 3个一级指标以及11个二级指标、30个三级指标组成的满分为10分的量化整合效果评价指标体系。2.城乡居民医保整合效果评价结果:从总体评价结果来看,样本市中东营的效果评价总得分在8分以上,其余4市总得分在7.5以上,在较短的整合时间内,山东省的城乡居民医保整合取得了一定成效。制度建设情况指标得分较高,制度落实情况和制度实施效果部分的指标则相对失分较多。从样本市之间的评价结果来看,东营总体得分最高,且三个一级指标的得分均为最高;济宁的总体得分最低,比总得分最高的东营低了 16.33个百分点。样本市之间的总体得分差距较大。样本市之间,制度建设指标得分基本一致,相差不大;制度落实指标得分有一定差距,医保整合的制度落实效果存在差异；制度实施效果指标得分差距较大。讨论与建议山东省城乡居民医保整合已在整体上取得一定成效,但目前医保整合尚存在诸多亟待解决的问题。在城乡居民医保整合的制度建设方面,基本制度建设较为完备,但医保经办管理体系建设尚不完善,大病与基本医保管办分离,管理体制尚未理顺。制度落实方面,筹资、补偿制度落实较好,但地域间居民医保整合制度的落实存在差异,基金管理和监督制度部分缺位,基金运行存在风险。制度实施效果方面,制度覆盖全面,参保居民受益程度提高且满意度较高,但医保制度对居民医疗服务分流的引导作用不明显,医疗费用过快增长抵减了医保制度抵御疾病经济风险的作用,居民对医保制度的认识不到位,影响制度的落实效果。为此提出进一步完善山东省城乡居民医保整合的建议:加强医保管理队伍建设;理顺大病医保管理体制;加强对医保制度运行的监管;强化医保制度对医药服务的政策导向；加大对医保整合的宣传力度。
[Abstract]:The basic medical insurance system of the residents in China has been established on the basis of the difference in the social and economic development of two yuan in urban and rural areas since the founding of the people's Republic of China. The system construction has shown a diversity and fragmented bad characteristics. With the development of the social economy, the unequal malpractices of urban and rural areas brought by different medical insurance systems are becoming increasingly prominent. The system of conservation and new rural cooperation belongs to the different management departments, the financing and the security level gap is large. It does not adapt to the goal of ensuring the equity of the health rights and interests of urban and rural residents and the goal of realizing the universal medical insurance system. It has a negative impact on the sustainable and healthy development of the social security system. The basic medical insurance system of urban and rural residents has become an economic society. To this end, the State Council and the eighteen Party of the party all put forward the requirements to eliminate urban and rural differences and realize the integration of urban and rural medical insurance system. In 2016, the State Council on the integration of urban and rural residents' basic medical insurance system was more specific to the integration of medical insurance and NCMS in the provinces. In 2014, Shandong province began to implement the integration of urban and rural residents' medical insurance system in the province. In 2015, the basic medical insurance system of urban and rural residents was implemented, but the evaluation of the integration effect of medical insurance for urban and rural residents has not been carried out. In order to summarize the problems in the process of medical insurance integration in urban and rural residents in time, further improve the integration of medical insurance. System, it is necessary to systematically evaluate the integration process and effect in order to ensure the health and sustainability of the medical insurance system of urban and rural residents. The significance and purpose of the research on the integration effect of medical insurance in urban and rural residents in Shandong province is systematically evaluated. It is intended to summarize the effectiveness and problems of the integration of medical insurance in Shandong Province in time, for the integration of medical insurance in urban and rural areas in Shandong province. Further improvement provides strategic suggestions, which is of great significance to the construction and sustainable development of medical insurance system for residents. At the same time, through the research and construction of the evaluation index system for the integration effect of medical insurance, it can make up the vacancy of the evaluation and Research on the medical insurance integration system of urban and rural residents and provide the basis for other provinces and cities to carry out the integration evaluation of medical insurance in urban and rural areas. The main purpose of this study is to systematically evaluate the effects of the integration of medical insurance in urban and rural residents in Shandong province by constructing the evaluation index system, to make clear the specific results and problems of medical insurance integration, and to provide policy suggestions for further improvement of medical insurance integration in urban and rural residents. The evaluation index system was constructed by the analytic hierarchy process (AHP). 5 samples of Dongying, Weihai, Zibo, Linyi and Jining were studied, and the sample medical insurance management agencies, medical institutions and the insured households were randomly selected from the sample city. The data were obtained by questionnaire survey and interview. The determined "scoring rules" score the sample city indicators and calculate the evaluation results. Results 1. the results of the evaluation index system of the medical insurance integration effect of urban and rural residents: the study established the 3 first levels of "system construction", "system implementation", "system implementation effect", and 11 two level indicators, and 30 three level indicators. The result of the evaluation of medical insurance integration effect of urban and rural residents with a full score of 10 points of quantitative integration effect evaluation index system.2.: from the overall evaluation results, the total score of the effect evaluation of the middle east battalion in the sample city is above 8 points, the total score of the other 4 cities is above 7.5. In the short integration time, the medical insurance integration of the urban and rural residents in Shandong province has been obtained. The system construction index score is high, the system implementation situation and the system implementation effect part are relatively lost. From the evaluation results of the sample City, Dongying has the highest overall score, and the three first grade indexes are the highest, the Jining total body score is the lowest, which is 16. lower than the Dongying with the highest total score. 33 percentage points. The overall score gap between the sample cities is large. Among the sample cities, the system construction index scores are basically the same, the difference is small; the system implementation indicators have a certain gap, the system implementation effect of the medical insurance integration is different; the system implementation effect index score difference is large. Discussion and suggestion on the medical insurance of urban and rural residents in Shandong Province The integration has achieved certain results in the whole, but there are still many problems to be solved in the integration of medical insurance. In the system construction of medical insurance integration of urban and rural residents, the construction of basic system is relatively complete, but the construction of the management system of medical insurance management system is not perfect, the major diseases and basic medical insurance management system are separated, the management system has not been straightened out. There are differences in the implementation of medical insurance integration system among regional residents, the lack of fund management and supervision system and the risk of fund operation. The effect of medical insurance system against the risk of disease economy is reduced by the rapid growth of medical expenses, and the residents' understanding of the medical insurance system is not in place, and the effect of the system is affected. Therefore, the suggestion of further perfecting the integration of medical insurance in urban and rural residents in Shandong province is put forward: strengthening the construction of medical insurance management team and straightening out the medical insurance management of the great disease. We should strengthen supervision over the operation of the medical insurance system, strengthen the policy orientation of the medical insurance system for medical services, and intensify publicity efforts on the integration of medical insurance.

【学位授予单位】：山东大学
【学位级别】：硕士
【学位授予年份】：2017
【分类号】：R197.1;F842.684

【相似文献】