城镇职工基本医疗保险统筹基金流失风险的调查
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摘要
随着社会医疗保险的快速发展,参保人数不断增加,医保基金规模日益扩大,城镇职工在医疗保险占相当大的比例,参保状态相对稳定,所享受待遇较高,如何做好防范城镇职工医保基金流失,已经成为一个重要社会难题。
为了确保城镇医疗保险基金能够有效的发挥作用,真正的把医保基金的钱用在参保人的身上,尽可能的发挥基金的最大作用,国家也出台了一系列管理基金的办法与规定,然而,在实际的情况中,医保统筹基金被浪费,骗取、挪用甚至贪污的现象在各地不同程度的存在,严重损害医保基金的使用效果和效率。
通过深入分析医疗保险的宏观政策和医疗机构的微观运行,提出防范城镇职工医疗保险基金流失的有效手段和途径。本文结合Z市医疗保险运行有关情况,从医疗保险基金收入和支出两个方面分析基金运行中存在的风险、运行风险形成的主要原因,主要来自参保单位规避、参保人员和医疗机构的道德风险、医保政策调整、高额医疗费用增长,提出应扩面增收、增强医保基金的抗风险能力；加大医保基金稽查力度和处罚力度,规避参保单位的道德风险；加强政策宣传及制定处罚措施,防范参保人员的道德风险；加快网络信息系统建设,实现高效优质的管理。同时要规范医疗行为,加快医疗机构的配套改革、进一步加强对定点医疗机构的监督和管理、探索建立医疗保险的完整体系、努力培养一支专业素质高的医疗保险检查稽核队伍、加大宣传力度、增强参保者维权意识等五个方面提出对策建议,确保医疗保险事业全面、协调、可持续发展。
With the rapid development of social medical insurance, the insured population increases ceaselessly, health insurance fund dimensions expands increasingly, urban workers in the medical insurance accounts for a considerable proportion of insurance status, relatively stable, enjoy treatment high, how to do well in prevention of medical insurance for urban workers, the outflow of funds, has become an important social problem.
In order to ensure the medical insurance funds can play an effective role, true to the health insurance fund for insurance money in the US, as far as possible to fund the biggest effect, countries have also introduced a series of fund management measure and regulation, however, in the actual situation of medical insurance fund, waste, fraud, embezzlement and corruption in varying degrees throughout the existence of serious damage to health insurance fund, the use effect and efficiency.
Through a thorough analysis of the medical insurance policy and medical institutions of the microscopic operation,put forward to be on guard the employee medical insurance fund loss of effective means and ways.The paper analyzes the risks of medical insurance fund operation from the medical insurance fund income and expenditure,by considering some situation of medical insurance operation in Z County.The risk come mainly from insurance units evasion,moral hazard of the insurance and medical institutions,policy adjustment,and high medical costs. It suggests that we should extend coverage and increase income,boost up the Fund's ability to resist risks,increase the intensity of fund management and penalties,avoid moral hazard of the insurance units, raise the level of medical insurance coordinate and enhance coordination capacity,strengthen policy advocacy and set penalties to prevent moral hazard insurance personnel.We also neel to improve the management and monitoring of medical insurance agencies to from an effective supervision and restraining mechanism;speed up network information system for efficient quality management。Some suggestions were proposed from accelerating the correlative reform of medical institution,strengthening the management and supervision of lisited medical institution,establishing integrity system of medical insurance,cultivating professional audit talents for medical insurance, enhancing the propaganda,enforcing the consciousness of vindicating rights and interests for insurants. In order to ensure the development of medical insurance comprehensive coordinated and sustainable.
为了确保城镇医疗保险基金能够有效的发挥作用,真正的把医保基金的钱用在参保人的身上,尽可能的发挥基金的最大作用,国家也出台了一系列管理基金的办法与规定,然而,在实际的情况中,医保统筹基金被浪费,骗取、挪用甚至贪污的现象在各地不同程度的存在,严重损害医保基金的使用效果和效率。
通过深入分析医疗保险的宏观政策和医疗机构的微观运行,提出防范城镇职工医疗保险基金流失的有效手段和途径。本文结合Z市医疗保险运行有关情况,从医疗保险基金收入和支出两个方面分析基金运行中存在的风险、运行风险形成的主要原因,主要来自参保单位规避、参保人员和医疗机构的道德风险、医保政策调整、高额医疗费用增长,提出应扩面增收、增强医保基金的抗风险能力；加大医保基金稽查力度和处罚力度,规避参保单位的道德风险；加强政策宣传及制定处罚措施,防范参保人员的道德风险；加快网络信息系统建设,实现高效优质的管理。同时要规范医疗行为,加快医疗机构的配套改革、进一步加强对定点医疗机构的监督和管理、探索建立医疗保险的完整体系、努力培养一支专业素质高的医疗保险检查稽核队伍、加大宣传力度、增强参保者维权意识等五个方面提出对策建议,确保医疗保险事业全面、协调、可持续发展。
With the rapid development of social medical insurance, the insured population increases ceaselessly, health insurance fund dimensions expands increasingly, urban workers in the medical insurance accounts for a considerable proportion of insurance status, relatively stable, enjoy treatment high, how to do well in prevention of medical insurance for urban workers, the outflow of funds, has become an important social problem.
In order to ensure the medical insurance funds can play an effective role, true to the health insurance fund for insurance money in the US, as far as possible to fund the biggest effect, countries have also introduced a series of fund management measure and regulation, however, in the actual situation of medical insurance fund, waste, fraud, embezzlement and corruption in varying degrees throughout the existence of serious damage to health insurance fund, the use effect and efficiency.
Through a thorough analysis of the medical insurance policy and medical institutions of the microscopic operation,put forward to be on guard the employee medical insurance fund loss of effective means and ways.The paper analyzes the risks of medical insurance fund operation from the medical insurance fund income and expenditure,by considering some situation of medical insurance operation in Z County.The risk come mainly from insurance units evasion,moral hazard of the insurance and medical institutions,policy adjustment,and high medical costs. It suggests that we should extend coverage and increase income,boost up the Fund's ability to resist risks,increase the intensity of fund management and penalties,avoid moral hazard of the insurance units, raise the level of medical insurance coordinate and enhance coordination capacity,strengthen policy advocacy and set penalties to prevent moral hazard insurance personnel.We also neel to improve the management and monitoring of medical insurance agencies to from an effective supervision and restraining mechanism;speed up network information system for efficient quality management。Some suggestions were proposed from accelerating the correlative reform of medical institution,strengthening the management and supervision of lisited medical institution,establishing integrity system of medical insurance,cultivating professional audit talents for medical insurance, enhancing the propaganda,enforcing the consciousness of vindicating rights and interests for insurants. In order to ensure the development of medical insurance comprehensive coordinated and sustainable.
引文
[1]乌日图.中国医疗保险制度改革思路[J].国际医药卫生导报,2009(9)
[2]黄承,刘欣.基本医疗保险适度水平相关研究综述和启示[J].2010(4)
[3]朱云杰,孙林岩,吕坚.城镇职工基本医疗保险制度相关主体行为的经济学分析[J].陕西工学院学报,2011(3)
[4]王延中.我国公共卫生制度的问题及出路[J].中国卫生经济,2011(11)
[5]Saez,M.Murillo.C.Shared features in Priees:income and Price elastieizes for healtheareexpenditures[J].Health E.eonomies,2011,13:267-279
[6]孟庆跃.医疗保险支付方式改革对费用控制的影响分析[J].卫生经济研究,2008(9)
[7]刘慧侠,赵守国.我国政府介入医疗保险的政策研究[J].中国软科学,2009(11)
[8]Pfaff,M.Difference in health care spending across countries:statistical evidence.Joumal of Health Polities,PolieyandUW,2011,15:1-65
[9]沈华亮.德国、法国医疗保险制度及其对我国医改的启示.中国卫生事业管理.2010,7：441-442
[10]David Dranove,Demand Inducement and the Physician-Patient Relationship,Economics and Statistics,2009(52) page121-133
[11]张新民,叶世雄等.加拿大医疗保险制度及其借鉴.中国卫生事业管理.2008,10：511-513
[12]Martin S.Feldstein,The Rising Price of Physician Services,Renew of Economics and Statistics,2010(52) page 121-133
[13]张成利.加大定点医疗机构的稽核力度.中国医疗保险.2011,3
[14]周云.不完全竞争医疗保健市场的福利状况分析[J].卫生经济研究,2010(5)
[15]熊茂友.我国医疗保险制度改革的难点与对策[J].国际医药卫生导报,2009(11)
[16]王鸿勇,牛钟顺.医疗保险费用控制机制的发展趋势[J].国外医学,2008(3)
[17]郭婷婷,牛侨,赵俊康.商业医疗保险与社会医疗保险风险分析及对策[J].卫生软件科学,2010(4)
[18]王勤.新加坡的医疗保障制度.当代亚太.2012,3；41-43
[19]NewhouseJ.P.and the Insureance Experiment GouP.Free of all Lessons from the RAND health insurance experiment [D].Harvard University Press,2008
[20]陆燕淳.借鉴管理式医疗保险制度[J].上海金融,2010(1)
[21]岳颂东.法国医疗保险制度及其启示.管理世界.2007,4：44-48
[22]仇雨临.国外医疗保险制度的主要问题与改革[J].卫生经济研究,2011(11)
[23]Kenneth Joseph Arrow.Uncertainty and the Welfare Economics of Medical care,The Americian Economics Review,2010(4).Page 942-973
[24]Pauly Mark V.The eonomics of moral hazard:eomment [J].Health Economie Review,2008,58:531-537
[25]Eggleston K,Risk Selection and Optimal Health Insurance-provider payment systems,TheJourn 2011
[26]赵小苏,王永其,宋余庆,王建宏,城镇基本医疗保险的道德风险及其防范[J].卫生经济研究,2011(7)
[27]陈永升.医疗保险中医疗供方道德风险行为分析[J].新疆财经学院学报,2012(4)
[28]毛瑛,李娇凤.城镇职工基本医疗保险道德风险的防范研究[J].中国医学伦理学,2010(8)
[29]周丽涛,毛瑛.医疗保险中医生的双重代理身份及其带来问题的研究[J].中国医学伦理学,2009(6)
[30]宋余庆,王建宏.城镇职工基本医疗保险的道德风险防范[J].卫生经济研究,2011(7)
[31]王延中.建立多层次的医疗保险体系[J].政策,2012(2)
[32]郑秉文.信息不对称与医疗保险[J].经济社会体制比较,2008(6)
[33]贾静.浅谈医疗保险缴费基数稽核.中国医疗保险.2007,3
[34]王新辉.医生道德风险对基本医疗保险改革的影响[J].新疆农垦经济,2008(1)
[35]严娟.医保基金支付稽核的关键问题.中国医疗保险.2010,6
[36]郑庆华.医疗保险支付稽核管理要点.中国医疗保险.2009,6
[37]苏圣杰.健康管理与商业健康保险道德风险防范[J].中国金融,2009(2)
[38]史晓滨.论在信息不对称状况下健康险的管理[J].保险研究,2010(2)
[39]Evans,Robert G-Supplier Indueed Demand:Some EmPirieal Evidence and ImPlieations [J].The Eeonomics of Health and MediealCare.2011
[40]金春林.控制医疗费用的策略重点应着眼于宏观层面[J].中国卫生资源,2012(3)
[2]黄承,刘欣.基本医疗保险适度水平相关研究综述和启示[J].2010(4)
[3]朱云杰,孙林岩,吕坚.城镇职工基本医疗保险制度相关主体行为的经济学分析[J].陕西工学院学报,2011(3)
[4]王延中.我国公共卫生制度的问题及出路[J].中国卫生经济,2011(11)
[5]Saez,M.Murillo.C.Shared features in Priees:income and Price elastieizes for healtheareexpenditures[J].Health E.eonomies,2011,13:267-279
[6]孟庆跃.医疗保险支付方式改革对费用控制的影响分析[J].卫生经济研究,2008(9)
[7]刘慧侠,赵守国.我国政府介入医疗保险的政策研究[J].中国软科学,2009(11)
[8]Pfaff,M.Difference in health care spending across countries:statistical evidence.Joumal of Health Polities,PolieyandUW,2011,15:1-65
[9]沈华亮.德国、法国医疗保险制度及其对我国医改的启示.中国卫生事业管理.2010,7：441-442
[10]David Dranove,Demand Inducement and the Physician-Patient Relationship,Economics and Statistics,2009(52) page121-133
[11]张新民,叶世雄等.加拿大医疗保险制度及其借鉴.中国卫生事业管理.2008,10：511-513
[12]Martin S.Feldstein,The Rising Price of Physician Services,Renew of Economics and Statistics,2010(52) page 121-133
[13]张成利.加大定点医疗机构的稽核力度.中国医疗保险.2011,3
[14]周云.不完全竞争医疗保健市场的福利状况分析[J].卫生经济研究,2010(5)
[15]熊茂友.我国医疗保险制度改革的难点与对策[J].国际医药卫生导报,2009(11)
[16]王鸿勇,牛钟顺.医疗保险费用控制机制的发展趋势[J].国外医学,2008(3)
[17]郭婷婷,牛侨,赵俊康.商业医疗保险与社会医疗保险风险分析及对策[J].卫生软件科学,2010(4)
[18]王勤.新加坡的医疗保障制度.当代亚太.2012,3；41-43
[19]NewhouseJ.P.and the Insureance Experiment GouP.Free of all Lessons from the RAND health insurance experiment [D].Harvard University Press,2008
[20]陆燕淳.借鉴管理式医疗保险制度[J].上海金融,2010(1)
[21]岳颂东.法国医疗保险制度及其启示.管理世界.2007,4：44-48
[22]仇雨临.国外医疗保险制度的主要问题与改革[J].卫生经济研究,2011(11)
[23]Kenneth Joseph Arrow.Uncertainty and the Welfare Economics of Medical care,The Americian Economics Review,2010(4).Page 942-973
[24]Pauly Mark V.The eonomics of moral hazard:eomment [J].Health Economie Review,2008,58:531-537
[25]Eggleston K,Risk Selection and Optimal Health Insurance-provider payment systems,TheJourn 2011
[26]赵小苏,王永其,宋余庆,王建宏,城镇基本医疗保险的道德风险及其防范[J].卫生经济研究,2011(7)
[27]陈永升.医疗保险中医疗供方道德风险行为分析[J].新疆财经学院学报,2012(4)
[28]毛瑛,李娇凤.城镇职工基本医疗保险道德风险的防范研究[J].中国医学伦理学,2010(8)
[29]周丽涛,毛瑛.医疗保险中医生的双重代理身份及其带来问题的研究[J].中国医学伦理学,2009(6)
[30]宋余庆,王建宏.城镇职工基本医疗保险的道德风险防范[J].卫生经济研究,2011(7)
[31]王延中.建立多层次的医疗保险体系[J].政策,2012(2)
[32]郑秉文.信息不对称与医疗保险[J].经济社会体制比较,2008(6)
[33]贾静.浅谈医疗保险缴费基数稽核.中国医疗保险.2007,3
[34]王新辉.医生道德风险对基本医疗保险改革的影响[J].新疆农垦经济,2008(1)
[35]严娟.医保基金支付稽核的关键问题.中国医疗保险.2010,6
[36]郑庆华.医疗保险支付稽核管理要点.中国医疗保险.2009,6
[37]苏圣杰.健康管理与商业健康保险道德风险防范[J].中国金融,2009(2)
[38]史晓滨.论在信息不对称状况下健康险的管理[J].保险研究,2010(2)
[39]Evans,Robert G-Supplier Indueed Demand:Some EmPirieal Evidence and ImPlieations [J].The Eeonomics of Health and MediealCare.2011
[40]金春林.控制医疗费用的策略重点应着眼于宏观层面[J].中国卫生资源,2012(3)