本文關(guān)鍵詞： 商業(yè)健康保險 道德風險 風險控制　出處：《廣西大學》2014年碩士論文　論文類型：學位論文

【摘要】：隨著我國市場經(jīng)濟的飛速發(fā)展和綜合國力的不斷提升,醫(yī)療衛(wèi)生水平也在逐步提高。在醫(yī)療技術(shù)日益進步的同時,醫(yī)療費用也以驚人的速度增長。我國社會主義初級階段的特征決定了我國現(xiàn)階段的社會醫(yī)療保障水平還存在一定的缺陷,商業(yè)健康保險的重要性正日益凸顯。目前,我國商業(yè)健康保險市場的發(fā)展還存在一定的不足：健康保險公司經(jīng)營利潤低,賠付高。健康保險的“第三方支付”模式存在嚴重缺陷,增加了醫(yī)患勾結(jié)的道德風險。依賴于藥價的醫(yī)療服務(wù)價格補償機制也為健康保險道德風險的滋生推波助瀾。在道德風險頻發(fā)的今天,市場行為主體之間的信任缺失,正常的市場行為主體關(guān)系已被扭曲。建立一個良性運行的健康保險體系,保持商業(yè)健康保險市場主體利益行為的均衡,不僅有利于滿足廣大群眾的醫(yī)療需求,還能更好的支持醫(yī)療體制改革,促進經(jīng)濟的發(fā)展和社會的穩(wěn)定。 本文以博弈論相關(guān)的概念、模型為依據(jù),構(gòu)造了健康保險參與人之間的博弈模型。模型結(jié)果證明,道德風險成本直接受到保險公司監(jiān)管水平和監(jiān)管力度的影響。增加醫(yī)療機構(gòu)和被保險人因違約或欺詐而承擔的風險成本,會在一定程度上減少道德風險行為,并且能夠有效維護雙方的合法權(quán)益。保險公司必須提高自身風險管控能力,采用多渠道、多策略的方式去加強醫(yī)療服務(wù)需求方和供給方的監(jiān)管,建立利益共享的激勵機制,改善健康保險公司經(jīng)營狀況,從根本上遏制道德風險行為的發(fā)生。本文還借鑒美國商業(yè)健康保險的成功經(jīng)驗,從美國商業(yè)健康保險市場發(fā)展現(xiàn)狀入手,探索美國商業(yè)健康保險防范道德風險的新技術(shù),深入研究了管理式醫(yī)療在遏制道德風險行為方面的有效措施。文章結(jié)合中國的具體國情,從醫(yī)療機構(gòu)、被保險人、保險公司內(nèi)部和醫(yī)療服務(wù)監(jiān)督方四個層面深入探討了中國商業(yè)健康保險道德風險的控制問題。通過保險公司、醫(yī)療機構(gòu)、社會監(jiān)督三管齊下,更好地發(fā)揮商業(yè)健康保險的重要作用。
[Abstract]:With the rapid development of China's market economy and the continuous improvement of comprehensive national strength, the level of medical and health care is also gradually improving. Medical expenses are also increasing at an alarming rate. The characteristics of the primary stage of socialism in China determine that there are still some defects in the level of social medical security at the present stage of our country. The importance of commercial health insurance is becoming increasingly prominent. At present, the development of commercial health insurance market in China still has some shortcomings: the operating profit of health insurance companies is low. The "third party payment" model of health insurance is seriously flawed. It increases the moral hazard of doctor-patient collusion. The compensation mechanism of medical service price which depends on the drug price also contributes to the development of moral hazard of health insurance. Lack of trust among market actors, the normal relationship between market actors has been distorted. Establish a healthy health insurance system to maintain the balance of commercial health insurance market interest behavior. Not only to meet the medical needs of the masses, but also to better support the reform of the medical system, promote economic development and social stability. Based on the related concepts and models of game theory, this paper constructs a game model between health insurance participants. The cost of moral hazard is directly affected by the level and intensity of supervision of insurance companies. Increasing the risk cost of medical institutions and insured due to breach of contract or fraud will reduce moral hazard behavior to a certain extent. And can effectively protect the legitimate rights and interests of both sides. Insurance companies must improve their own risk control ability, adopt multi-channel, multi-strategy way to strengthen the medical service demand-side and supply-side supervision. To establish an incentive mechanism for benefit-sharing, improve the management of health insurance companies, and fundamentally curb the occurrence of moral hazard behavior. This article also draws lessons from the successful experience of commercial health insurance in the United States. Starting with the development of American commercial health insurance market, this paper explores the new technology of American commercial health insurance against moral hazard. This paper deeply studies the effective measures of management medical treatment in curbing moral hazard behavior. The article combines with the specific conditions of China, from medical institutions, insured. This paper probes into the control of moral hazard in China's commercial health insurance from four aspects: insurance company internal and medical service supervisor. Through insurance company, medical institution and social supervision, there are three aspects: insurance company, medical institution and social supervision. Better play the important role of commercial health insurance.
【學位授予單位】：廣西大學
【學位級別】：碩士
【學位授予年份】：2014
【分類號】：F842.684

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