本文關(guān)鍵詞： 鄭州市 醫(yī)療保險(xiǎn) 統(tǒng)籌　出處：《鄭州大學(xué)》2014年碩士論文　論文類型：學(xué)位論文

【摘要】：目的 本文以鄭州市城鎮(zhèn)職工基本醫(yī)療保險(xiǎn)、城鎮(zhèn)居民基本醫(yī)療保險(xiǎn)、新型農(nóng)村合作醫(yī)療制度為對(duì)象，從經(jīng)辦管理、覆蓋范圍、籌資金額、待遇水平、醫(yī)療服務(wù)和信息系統(tǒng)等方面入手，研究其在運(yùn)行過(guò)程中存在的體制和機(jī)制障礙，探討鄭州市統(tǒng)籌城鄉(xiāng)醫(yī)療保險(xiǎn)制度的方案，以期為深化醫(yī)藥衛(wèi)生體制改革、建立健全醫(yī)療保險(xiǎn)制度提供實(shí)踐依據(jù)。 方法 在文獻(xiàn)分析的基礎(chǔ)上，查詢鄭州歷年統(tǒng)計(jì)公報(bào)、醫(yī)療保險(xiǎn)相關(guān)文件、統(tǒng)計(jì)報(bào)表、工作總結(jié)，運(yùn)用比較研究法分析鄭州市城鎮(zhèn)職工基本醫(yī)療保險(xiǎn)、城鎮(zhèn)居民基本醫(yī)療保險(xiǎn)及新型農(nóng)村合作醫(yī)療制度在管理部門(mén)、參保對(duì)象、管理機(jī)構(gòu)、籌資政策、待遇政策、服務(wù)范圍、信息系統(tǒng)等方面的異同；采用半結(jié)構(gòu)訪談法了解鄭州市醫(yī)療保險(xiǎn)制度設(shè)計(jì)、管理模式、運(yùn)行情況，分析統(tǒng)籌城鄉(xiāng)社會(huì)醫(yī)療保險(xiǎn)制度的必要性和可行性；采用頭腦風(fēng)暴法探討鄭州市統(tǒng)籌城鄉(xiāng)醫(yī)療保險(xiǎn)制度改革措施。 結(jié)果 1.研究發(fā)現(xiàn)，鄭州市城鎮(zhèn)職工基本醫(yī)療保險(xiǎn)、城鎮(zhèn)居民基本醫(yī)療保險(xiǎn)、新型農(nóng)村合作醫(yī)療在以下幾個(gè)方面存在不同：管理方面，相互獨(dú)立，各自為政；覆蓋范圍方面，醫(yī)療保險(xiǎn)制度設(shè)計(jì)對(duì)戶籍有明確限制；籌資金額方面，城鎮(zhèn)職工基本醫(yī)療保險(xiǎn)明顯高于另外兩個(gè)保險(xiǎn)，城鎮(zhèn)居民基本醫(yī)療保險(xiǎn)和新型農(nóng)村合作醫(yī)療的籌資金額較為接近，但在個(gè)人負(fù)擔(dān)方面仍有差別；待遇水平方面，在起付標(biāo)準(zhǔn)、報(bào)銷比例、最高支付限額、普通門(mén)診、慢病種類等方面存在差異；服務(wù)范圍方面，城鎮(zhèn)職工基本醫(yī)療保險(xiǎn)、城鎮(zhèn)居民基本醫(yī)療保險(xiǎn)適用相同的藥品目錄，相同的定點(diǎn)醫(yī)療機(jī)構(gòu)范圍和定點(diǎn)藥店范圍，但兩者在結(jié)算辦法方面仍有差異，新型農(nóng)村合作醫(yī)療的藥品目錄、定點(diǎn)醫(yī)療機(jī)構(gòu)范圍、結(jié)算辦法與前兩者有較大差別，其醫(yī)療服務(wù)范圍明顯低于前兩者；信息系統(tǒng)方面，城鎮(zhèn)職工基本醫(yī)療保險(xiǎn)和城鎮(zhèn)居民基本醫(yī)療保險(xiǎn)共享同一信息平臺(tái)，新型農(nóng)村合作醫(yī)療則有其獨(dú)自的信息系統(tǒng)，自成體系。 2.鄭州市現(xiàn)行醫(yī)療保險(xiǎn)制度在設(shè)計(jì)和運(yùn)行中存在一些弊端，亟待改革統(tǒng)籌。如：制度碎片化，，管理低效率，報(bào)銷程序繁瑣；各險(xiǎn)種相互獨(dú)立，各自為政，信息系統(tǒng)不統(tǒng)一；重復(fù)參保、重復(fù)報(bào)銷、財(cái)政重復(fù)補(bǔ)貼等，造成資金浪費(fèi)；監(jiān)督制約機(jī)制缺失等。 結(jié)論 1．鄭州市已建立了廣覆蓋、多層次的醫(yī)療保障體系，城鎮(zhèn)職工、城鎮(zhèn)居民和廣大農(nóng)村居民都可以享有基本醫(yī)療保險(xiǎn)，為進(jìn)一步統(tǒng)籌優(yōu)化奠定了基礎(chǔ)。 2．鄭州市現(xiàn)行的城鄉(xiāng)二元醫(yī)療保險(xiǎn)體系在實(shí)際運(yùn)行中引發(fā)了一系列問(wèn)題，統(tǒng)籌改革城鄉(xiāng)醫(yī)療保險(xiǎn)制度勢(shì)在必行。 3．改革的關(guān)鍵是：在體制上，打破戶籍制度壁壘，設(shè)立統(tǒng)一的管理和經(jīng)辦部門(mén)，建立統(tǒng)一的信息服務(wù)平臺(tái)；在機(jī)制上，設(shè)立不同檔次的籌資標(biāo)準(zhǔn)，建立繳費(fèi)與報(bào)銷對(duì)等的待遇機(jī)制，充分發(fā)揮市場(chǎng)機(jī)制作用，最終實(shí)現(xiàn)統(tǒng)籌城鄉(xiāng)醫(yī)療保險(xiǎn)體系的目標(biāo)。
[Abstract]:Purpose. This article takes the basic medical insurance for urban workers, the basic medical insurance for urban residents and the new rural cooperative medical care system as the object, from the management, coverage, financing amount, treatment level, Starting with the medical service and information system, this paper studies the system and mechanism obstacles existing in the process of operation, and probes into the scheme of the urban and rural medical insurance system in Zhengzhou, in order to deepen the reform of the medical and health system. Establish and improve the medical insurance system to provide practical basis. Method. On the basis of literature analysis, the author inquires the Zhengzhou statistical bulletin, medical insurance related documents, statistical reports, work summary, and applies comparative research method to analyze the basic medical insurance for urban workers in Zhengzhou. The similarities and differences between the basic medical insurance of urban residents and the new rural cooperative medical system in the aspects of management department, insured object, management organization, financing policy, treatment policy, service scope, information system, etc. Using the method of semi-structure interview to understand the design, management mode and operation of medical insurance system in Zhengzhou, and analyze the necessity and feasibility of coordinating the social medical insurance system in urban and rural areas. This paper discusses the reform measures of urban and rural medical insurance system in Zhengzhou by using brainstorming method. Results. 1. It is found that the basic medical insurance for urban workers, the basic medical insurance for urban residents and the new rural cooperative medical insurance are different in the following aspects: management, independence, and coverage; The design of the medical insurance system has clear restrictions on household registration; in terms of the amount of capital raised, the basic medical insurance for urban workers is obviously higher than the other two. The amount of funding for the basic medical insurance for urban residents and the new rural cooperative medical scheme is relatively close. However, there are still differences in personal burdens; in terms of treatment level, there are differences in starting payment standards, reimbursement rates, maximum payment limits, general outpatient clinics, types of chronic diseases, and so on; in terms of service scope, basic medical insurance for urban workers and staff, The basic medical insurance for urban residents shall be subject to the same drug catalogue, the same scope of designated medical institutions and the scope of designated pharmacies, but there are still differences between the two in terms of settlement measures. There is a great difference between the settlement measures and the former two, and the scope of medical services is obviously lower than that of the former two. In the information system, the basic medical insurance for urban workers and the basic medical insurance for urban residents share the same information platform, The new rural cooperative medical system has its own information system and its own system. 2. There are some drawbacks in the design and operation of the current medical insurance system in Zhengzhou, such as fragmentation of the system, low efficiency of management, complicated reimbursement procedures, independence of each type of insurance, and disunity of information system. Repeated participation in insurance, repeated reimbursement, repeated financial subsidies, etc., resulting in waste of funds; lack of supervision and control mechanism. Conclusion. 1. Zhengzhou has established a medical security system with wide coverage and multi-level coverage. Urban workers, urban residents and rural residents can enjoy basic medical insurance, which has laid the foundation for further overall planning and optimization. 2. The current urban-rural dual medical insurance system in Zhengzhou has caused a series of problems in the actual operation, so it is imperative to reform the urban-rural medical insurance system as a whole. 3. The key to the reform is to break down the barriers to the household registration system, to establish a unified management and administrative department, and to establish a unified information service platform. Establishing the equal treatment mechanism of payment and reimbursement, giving full play to the role of market mechanism, and finally realizing the goal of coordinating urban and rural medical insurance system.
【學(xué)位授予單位】：鄭州大學(xué)
【學(xué)位級(jí)別】：碩士
【學(xué)位授予年份】：2014
【分類號(hào)】：F842.684;R197.1

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