大连市城镇基本医疗保险基金收支影响因素的实证研究
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摘要
自1998年12月,《国务院关于建立城镇职工基本医疗保险制度的决定》出台后,中国的城镇基本医疗保险制度一直在不断的发展及完善中,2007年在全国一些城市开展城镇居民医疗保险试点工作,自此医疗保险覆盖范围进一步扩大。医疗保险制度的运行过程中存在许多问题,其中,医疗保险基金的收支平衡问题逐渐得到了社会各界的关注,也成为目前医疗保险制度运行中的热点问题之一。
本文选取了大连市城镇基本医疗保险基金的社会统筹账户为实证研究对象,从基金收支两方面分别建立了精算模型,按照精算方法中的现值法,根据大连市现有数据,对收支情况及影响因素进行测算,目的是研究各个影响因素分别对基金收支的具体影响程度,进而找出缓解大连市城镇基本医疗保险基金收支平衡压力的措施。
第一章为绪论部分,主要介绍研究背景、理论基础、国内外研究现状以及本文的创新点及不足,其中,理论基础主要选择了福利经济学、大数法则、市场失灵理论、健康管理理论以及医疗保险精算理论进行介绍；第二章阐述了大连市城镇基本医疗保险基金的制度变迁情况、收支情况以及基金运行中存在的问题,目前大连市城镇职工医疗保险制度已趋于成熟,但城镇居民医疗保险制度尚处于起步阶段,还有许多发展空间,随着制度的不断完善,基金收支总额都随之上升,但仍较为严重的不平衡问题；第三章对影响城镇基本医疗保险基金的因素进行定性分析,第四章则结合基金收支情况,对影响因素进行定量分析；第五章为大连市城镇基本医疗保险基金实现“收支平衡,略有结余”的目标,提供了对策建议。
对医疗保险基金收支平衡的研究有许多,而运用精算方法进行测算,并未发展的十分成熟,本文选取精算方法,以大连市基金收支情况为基础,对影响因素进行实证研究,具有一定的现实意义。并且,在计算时添加了前人未考虑的门诊大病、慢性病费用以及通货膨胀率因素,是本文的创新所在。但由于基金运行过程较为复杂,数据较难收集,本文仅从现有的数据基础上进行研究,不可避免存在一些误差,这也是文章的不足之处。但已得出的结论仍然能够为大连市医疗保险相关部门制定基金收支标准时提供一些参考,对完善大连市的医保制度,具有政策和实践的指导作用。
Since "State Council on the Decision of Establishing the Basic Medical Insurance System for Urban Staff'came on in Dec.1998, Chinese government has been working on the sustainable development and approximate perfection of the basic medical insurance system for urban staff. A further expansion of health insurance coverage has grown since the experimental work of medical insurance for urban residents was carried out in a number of cities throughout the country in 2007. There exist many problems in the process of running the medical insurance system, including the problem of the balance between income and expenditure of Medical Insurance Fund, which has gradually been paid special attention to from all walks of life and also become a hot topic of running the medical insurance system.
The paper chooses social pooling accounts of urban basic medical insurance fund in Dalian City as positive research object, makes actuarial models respectively based on fund income and expenditure, and estimates the available data in Dalian City according to the present value method of actuarial science, aiming to study the specific impact made by each factor on the fund balance, coming to find the way of relieving the balance pressure of urban basic medical insurance fund.
The first thesis is the part of introduction, mainly introducing study background, theoretical basis, study situation at home and abroad, innovative ideas and flaws in this paper. The theoretical basis consists of welfare economics, law of large numbers, market failure theory, Health Management Theory and actuarial theory of medical insurance. Thesis two states the system changes and the financial balance of urban basic medical insurance fund in Dalian City, as well as the problems existing in the process of fund operation. Currently, the medical insurance system for urban employees in Dalian City has driven to maturity; however, the medical insurance system for urban residents is still in its infancy with abundant development space. With the continuous improvement of the medical insurance system, the total amount of fund balance also rise, along with the serious imbalance problem. Thesis three makes a qualitative analysis of the effect factors to urban basic medical insurance funds. Thesis four makes a qualitative analysis of the effect factors combining with the fund balance. The last thesis provides strategy and advice to achieve the aim of balance between financial revenue and expenditure with a small surplus.
There are plenty of studies on the balance of medical insurance funds, and the calculation by use of an actuarial method has not developed mature enough. It takes practical significance for this paper to adopt the actuarial method and make an empirical research based on the fund balance in Dalian City. Besides, the innovation lies to add the factors never to be considered of chronic disease expenses and inflation rate. However, owing that the fund operation has a complicated process, the data is difficult to accumulate, this paper makes a study only based on current data, and the inevitable error becomes the flaw of this paper. The conclusion still provide advice of making fund standard for the relevant departments of medical insurance in Dalian City.
本文选取了大连市城镇基本医疗保险基金的社会统筹账户为实证研究对象,从基金收支两方面分别建立了精算模型,按照精算方法中的现值法,根据大连市现有数据,对收支情况及影响因素进行测算,目的是研究各个影响因素分别对基金收支的具体影响程度,进而找出缓解大连市城镇基本医疗保险基金收支平衡压力的措施。
第一章为绪论部分,主要介绍研究背景、理论基础、国内外研究现状以及本文的创新点及不足,其中,理论基础主要选择了福利经济学、大数法则、市场失灵理论、健康管理理论以及医疗保险精算理论进行介绍；第二章阐述了大连市城镇基本医疗保险基金的制度变迁情况、收支情况以及基金运行中存在的问题,目前大连市城镇职工医疗保险制度已趋于成熟,但城镇居民医疗保险制度尚处于起步阶段,还有许多发展空间,随着制度的不断完善,基金收支总额都随之上升,但仍较为严重的不平衡问题；第三章对影响城镇基本医疗保险基金的因素进行定性分析,第四章则结合基金收支情况,对影响因素进行定量分析；第五章为大连市城镇基本医疗保险基金实现“收支平衡,略有结余”的目标,提供了对策建议。
对医疗保险基金收支平衡的研究有许多,而运用精算方法进行测算,并未发展的十分成熟,本文选取精算方法,以大连市基金收支情况为基础,对影响因素进行实证研究,具有一定的现实意义。并且,在计算时添加了前人未考虑的门诊大病、慢性病费用以及通货膨胀率因素,是本文的创新所在。但由于基金运行过程较为复杂,数据较难收集,本文仅从现有的数据基础上进行研究,不可避免存在一些误差,这也是文章的不足之处。但已得出的结论仍然能够为大连市医疗保险相关部门制定基金收支标准时提供一些参考,对完善大连市的医保制度,具有政策和实践的指导作用。
Since "State Council on the Decision of Establishing the Basic Medical Insurance System for Urban Staff'came on in Dec.1998, Chinese government has been working on the sustainable development and approximate perfection of the basic medical insurance system for urban staff. A further expansion of health insurance coverage has grown since the experimental work of medical insurance for urban residents was carried out in a number of cities throughout the country in 2007. There exist many problems in the process of running the medical insurance system, including the problem of the balance between income and expenditure of Medical Insurance Fund, which has gradually been paid special attention to from all walks of life and also become a hot topic of running the medical insurance system.
The paper chooses social pooling accounts of urban basic medical insurance fund in Dalian City as positive research object, makes actuarial models respectively based on fund income and expenditure, and estimates the available data in Dalian City according to the present value method of actuarial science, aiming to study the specific impact made by each factor on the fund balance, coming to find the way of relieving the balance pressure of urban basic medical insurance fund.
The first thesis is the part of introduction, mainly introducing study background, theoretical basis, study situation at home and abroad, innovative ideas and flaws in this paper. The theoretical basis consists of welfare economics, law of large numbers, market failure theory, Health Management Theory and actuarial theory of medical insurance. Thesis two states the system changes and the financial balance of urban basic medical insurance fund in Dalian City, as well as the problems existing in the process of fund operation. Currently, the medical insurance system for urban employees in Dalian City has driven to maturity; however, the medical insurance system for urban residents is still in its infancy with abundant development space. With the continuous improvement of the medical insurance system, the total amount of fund balance also rise, along with the serious imbalance problem. Thesis three makes a qualitative analysis of the effect factors to urban basic medical insurance funds. Thesis four makes a qualitative analysis of the effect factors combining with the fund balance. The last thesis provides strategy and advice to achieve the aim of balance between financial revenue and expenditure with a small surplus.
There are plenty of studies on the balance of medical insurance funds, and the calculation by use of an actuarial method has not developed mature enough. It takes practical significance for this paper to adopt the actuarial method and make an empirical research based on the fund balance in Dalian City. Besides, the innovation lies to add the factors never to be considered of chronic disease expenses and inflation rate. However, owing that the fund operation has a complicated process, the data is difficult to accumulate, this paper makes a study only based on current data, and the inevitable error becomes the flaw of this paper. The conclusion still provide advice of making fund standard for the relevant departments of medical insurance in Dalian City.
引文
① Arrow, Kenneth J. Uncertainty and the welfare economics of medical care[J].Health Economic Review,1963,53:941-973
①Evans, Robert G. Supplier — Induced Demand:Some Empirical Evidence and Implications [J].The Economics of Health and Medical Care,1974.
②陈滔、卓志、李良军、杨树勤.商业医疗保险的保费计算方法研究[J].保险研究,2002(4),32页
③李良军.以定额为基础的医疗保险金测算方法[J].中国卫生经济,1996(2)
①张思锋等.社会保障精算理论与应用[M].人民出版社,2006,191页
②李良军、杨树勤等.保险因子的初步研究[J].中国农村卫生事业管理,1994(4)
①李良军、杨树勤等.农村健康保险的精算体系[J].现代预防医学,1994(2),69-73页
①国务院办公厅转发国家体改委等四部委关于职工医疗保障制度改革扩大试点意见的通知,1996年5月5日
②张星.大连迈近“人人享医疗保障”[N].半岛晨报,2008-11-29
①大连城镇职工医保统筹启动,医保卡今起全市通用,中国日报,2011-07-01
②大连市人民政府关于印发大连市城镇居民基本医疗保险实施办法的通知,2007年8月25日
①基金收支的计算方法借鉴于胡恒的《中国“全国社保基金”资产负债分析》.东北财经大学,2006
①贾铁生.“十二五”末大连市城镇化率达75%以上[N].大连日报,2011-04-12
②数据来源于大连市统计年鉴(1991-2010)
①胡恒.中国“全国社保基金”资产负债分析.东北财经大学,2006
①辛敏娟.大连人口老龄化加速2015年老年人将占人口两成[N].半岛晨报,2011-04-01
[1]薄志超.风险理论模型及其应用[M].中南工业出版社,1994
[2]陈滔.医疗保险精算和风险控制方法[M].西南财经大学出版社,2002
[3]陈滔.健康保险精算：模型、方法和应用[M].北京：中国统计出版社,2007
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[5]戴伟辉、王欢等.社会医疗保险的医疗费用函数建模分析[J].中国卫生经济,2005(5)
[6]黄占辉、王汉亮.健康保险学[M].北京大学出版社,2006
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[8]李良军、杨树勤等.医药费用预测模型及保险因子分析[J].中国卫生事业管理,1994,5
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[11]李恒琦,张运刚.社会保险精算教程[M].西南财经大学出版社,2009
[12]林毓铭.医疗保险的核心机制：医疗保险基金收支平衡分析[J].中央财经大学学报,2001(12)
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[14]任仕泉等.统筹医疗保险保费测算方法研究[J].中国卫生事业管理杂志,2001(3)：154
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[16]宋世斌等.社会保险精算[M].中国劳动社会保障出版社,2007
[17]孙国桢.上海市实施医保费用总额控制的实践与体会[J].卫生经济研究,2002(12)
[18]谭中和.基于数据仓库技术的医疗保险基金风险管理模型及其实现[J].医学信息,2005(8)
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[21]王泽英、曾湘泉.灵活就业人员基本医疗保险预算分析[J].经济理论与经济管理,2004
[22]王晓军.社会保险精算原理与实务[M].中国人民大学出版社,2009
[23]王桂胜.社会保险精算[M].中国劳动社会保障出版社,2008
[24]汪泓.社会保险基金的良性运营：系统动力学模型、方法、应用[M].北京大学出版社,2008
[25]吴忠、汪泓.社会保险基金预警预报系统开发研究[M].北京大学出版社,2008
[26]伍超标.保险精算学基础[M].中国统计出版社,1999
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①Evans, Robert G. Supplier — Induced Demand:Some Empirical Evidence and Implications [J].The Economics of Health and Medical Care,1974.
②陈滔、卓志、李良军、杨树勤.商业医疗保险的保费计算方法研究[J].保险研究,2002(4),32页
③李良军.以定额为基础的医疗保险金测算方法[J].中国卫生经济,1996(2)
①张思锋等.社会保障精算理论与应用[M].人民出版社,2006,191页
②李良军、杨树勤等.保险因子的初步研究[J].中国农村卫生事业管理,1994(4)
①李良军、杨树勤等.农村健康保险的精算体系[J].现代预防医学,1994(2),69-73页
①国务院办公厅转发国家体改委等四部委关于职工医疗保障制度改革扩大试点意见的通知,1996年5月5日
②张星.大连迈近“人人享医疗保障”[N].半岛晨报,2008-11-29
①大连城镇职工医保统筹启动,医保卡今起全市通用,中国日报,2011-07-01
②大连市人民政府关于印发大连市城镇居民基本医疗保险实施办法的通知,2007年8月25日
①基金收支的计算方法借鉴于胡恒的《中国“全国社保基金”资产负债分析》.东北财经大学,2006
①贾铁生.“十二五”末大连市城镇化率达75%以上[N].大连日报,2011-04-12
②数据来源于大连市统计年鉴(1991-2010)
①胡恒.中国“全国社保基金”资产负债分析.东北财经大学,2006
①辛敏娟.大连人口老龄化加速2015年老年人将占人口两成[N].半岛晨报,2011-04-01
[1]薄志超.风险理论模型及其应用[M].中南工业出版社,1994
[2]陈滔.医疗保险精算和风险控制方法[M].西南财经大学出版社,2002
[3]陈滔.健康保险精算：模型、方法和应用[M].北京：中国统计出版社,2007
[4]程晓明.医疗保险学[M].复旦大学出版社,2003
[5]戴伟辉、王欢等.社会医疗保险的医疗费用函数建模分析[J].中国卫生经济,2005(5)
[6]黄占辉、王汉亮.健康保险学[M].北京大学出版社,2006
[7]李良军、杨树勤等.保险因子的初步研究[J].中国农村卫生事业管理,1994,4(14)
[8]李良军、杨树勤等.医药费用预测模型及保险因子分析[J].中国卫生事业管理,1994,5
[9]李良军.以定额为基础的医疗保险金测算方法[J].中国卫生经济,1996(2)
[10]李云良.医疗保险费用支出的经济学分析[J].卫生经济研究,2005(3)
[11]李恒琦,张运刚.社会保险精算教程[M].西南财经大学出版社,2009
[12]林毓铭.医疗保险的核心机制：医疗保险基金收支平衡分析[J].中央财经大学学报,2001(12)
[13]陆大祥.精算学及其在保险领域的运用[J].上海保险,1994(8)
[14]任仕泉等.统筹医疗保险保费测算方法研究[J].中国卫生事业管理杂志,2001(3)：154
[15]宋安.我国社会保障制度的风险研究[M].山西财经大学出版社,2006
[16]宋世斌等.社会保险精算[M].中国劳动社会保障出版社,2007
[17]孙国桢.上海市实施医保费用总额控制的实践与体会[J].卫生经济研究,2002(12)
[18]谭中和.基于数据仓库技术的医疗保险基金风险管理模型及其实现[J].医学信息,2005(8)
[19]田勇、冯振翼.医疗保险基本理论与实践[M].中国劳动社会保障出版社,2002
[20]王晓燕、宋学锋.老龄化过程中的医疗保险基金：对使用现状及平衡能力的分析[J].预测,2004(6)
[21]王泽英、曾湘泉.灵活就业人员基本医疗保险预算分析[J].经济理论与经济管理,2004
[22]王晓军.社会保险精算原理与实务[M].中国人民大学出版社,2009
[23]王桂胜.社会保险精算[M].中国劳动社会保障出版社,2008
[24]汪泓.社会保险基金的良性运营：系统动力学模型、方法、应用[M].北京大学出版社,2008
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