本文關(guān)鍵詞： 大連市職工 普通門診統(tǒng)籌 方案模擬　出處：《大連理工大學》2014年碩士論文　論文類型：學位論文

【摘要】：隨著醫(yī)療改革的逐漸深入,國內(nèi)許多城市已經(jīng)或者準備實行城鎮(zhèn)職工基本醫(yī)療保險普通門診統(tǒng)籌制度。大連市醫(yī)療保險制度的開展正面臨著以下幾點問題：較高的門診費用給就診患者帶來的經(jīng)濟負擔日益加重；三甲醫(yī)院人滿為患,基層機構(gòu)的醫(yī)療資源卻出現(xiàn)閑置和浪費的現(xiàn)象；基本醫(yī)保統(tǒng)籌基金短缺,但個人基金賬戶的資金卻大量沉淀,醫(yī)保資金并沒有得到充分的利用。鑒于以上問題,本文根據(jù)大連市實際門診就診情況,設(shè)計合理的普通門診統(tǒng)籌支付方案,以達到抑制門診次均費用過快增長的現(xiàn)象,促進大連市醫(yī)療資源的合理配置,提高醫(yī)保基金的使用效率的目的。 本文的研究內(nèi)容主要包括以下方面：(1)概述國外的職工基本醫(yī)療保險普通門診統(tǒng)籌制度,綜述與分析相應的研究工作；(2)通過對目前國內(nèi)門診統(tǒng)籌制度實施現(xiàn)狀的分析,結(jié)合大連市實際情況和相關(guān)的政策要求,確定大連市職工基本醫(yī)保普通門診統(tǒng)籌基金的籌集采用按比例劃撥方式,采用不設(shè)立起付線只設(shè)置封頂線,醫(yī)藥費用分段按比例報銷的門診基金支付政策,門診統(tǒng)籌基金按人頭付費,參保職工隨機選擇定點機構(gòu)就診的統(tǒng)籌方式；(3)依據(jù)本方案設(shè)計思路,分析目前大連市職工門診統(tǒng)籌基本數(shù)據(jù),預估下一年度大連市職工門診就診年齡結(jié)構(gòu),門診就診情況、醫(yī)藥費用水平及門診統(tǒng)籌基金的收支情況；(4)制定大連市職工基本醫(yī)保門診統(tǒng)籌方案,通過統(tǒng)計模擬和比較,評價并選擇方案；(5)對大連市職工基本醫(yī)療保險普通門診統(tǒng)籌制度提出建議,采用科學化的支付方式與合理的控制手段,構(gòu)建有效的職工基本醫(yī)療保險普通門診付費統(tǒng)籌制度。
[Abstract]:With the deepening of health care reform, Many cities in China have already implemented or intend to implement the general out-patient planning system for urban workers' basic medical insurance. The development of Dalian's medical insurance system is facing the following problems: higher outpatient expenses bring to patients. Increasing economic burden; Third Class A Hospitals are overcrowded, but the medical resources of grass-roots institutions are idle and wasteful; the basic health insurance fund is short, but the funds in the personal fund account are precipitated in large quantities. The medical insurance fund has not been fully utilized. In view of the above problems, according to the actual outpatient service in Dalian, this paper designs a reasonable general out-patient payment scheme, in order to restrain the phenomenon that the average outpatient expenses increase too fast. To promote the rational allocation of medical resources in Dalian and to improve the efficiency of medical insurance funds. The research content of this paper mainly includes the following aspects: 1) summarizing the general out-patient coordination system of foreign workers' basic medical insurance, summarizing and analyzing the corresponding research work and analyzing the current situation of the implementation of the domestic out-patient coordination system. In combination with the actual situation in Dalian and the relevant policy requirements, it is determined that the raising of the general out-patient general out-patient fund for basic medical insurance in Dalian adopts the method of proportional transfer, and the ceiling line is only set up without the establishment of the starting line. The policy of outpatient fund payment in proportion to the proportion of medical expenses, the outpatient plan fund is paid according to the head of the person, the participating staff and workers randomly select the overall way of seeing a doctor by designated organization.) according to the design idea of this scheme, By analyzing the current basic data of Dalian workers' outpatient service as a whole, and predicting the age structure and outpatient visit status of Dalian workers' outpatient service in the next year, Level of Medical expenses and income and Expenditure of the Out-patient Co-ordinating Fund. (4) to formulate an overall plan for the out-patient planning of basic medical insurance for workers in Dalian, through statistical simulation and comparison, To evaluate and select the scheme 5) to put forward suggestions on the general out-patient coordination system of basic medical insurance for workers in Dalian, and to construct an effective general out-patient payment system of basic medical insurance for workers by adopting scientific payment method and reasonable control means.
【學位授予單位】：大連理工大學
【學位級別】：碩士
【學位授予年份】：2014
【分類號】：F842.684

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本文編號：1531108