本文選題：新農(nóng)合大病保險(xiǎn)　切入點(diǎn)：風(fēng)險(xiǎn)識(shí)別　出處：《山東大學(xué)》2014年碩士論文　論文類型：學(xué)位論文

【摘要】：由原來(lái)的公費(fèi)醫(yī)療到全民醫(yī)保，我國(guó)醫(yī)療保障體系不斷完善和深化�，F(xiàn)階段我國(guó)基本醫(yī)療保障水平比較低，特別是對(duì)重大疾病的保障存在不足。醫(yī)療費(fèi)用個(gè)人負(fù)擔(dān)重，因病致貧、因病返貧現(xiàn)象比較普遍。為了提高城鄉(xiāng)居民醫(yī)療保障水平，2012年國(guó)家發(fā)布了《關(guān)于開(kāi)展城鄉(xiāng)居民大病保險(xiǎn)工作的指導(dǎo)意見(jiàn)》，引入市場(chǎng)機(jī)制，建立大病保險(xiǎn)制度，減輕居民的大病負(fù)擔(dān)。保險(xiǎn)公司也以社會(huì)管理者的身份參與到我國(guó)醫(yī)療衛(wèi)生改革的浪潮中。 城鄉(xiāng)居民大病保險(xiǎn)即將在全國(guó)鋪開(kāi)實(shí)施，通過(guò)全面識(shí)別風(fēng)險(xiǎn)因素和科學(xué)風(fēng)險(xiǎn)評(píng)估，可以讓決策者了解現(xiàn)階段大病保險(xiǎn)面臨的風(fēng)險(xiǎn)狀況，還能為決策機(jī)關(guān)調(diào)整工作方式起指導(dǎo)作用，對(duì)大病保險(xiǎn)穩(wěn)健運(yùn)營(yíng)有重要意義。 回顧以往文獻(xiàn)資料，前人對(duì)社會(huì)醫(yī)療保險(xiǎn)的總結(jié)和研究多集中于基金風(fēng)險(xiǎn)、管理模式等具體問(wèn)題的探討，對(duì)運(yùn)營(yíng)風(fēng)險(xiǎn)的全面識(shí)別和測(cè)算問(wèn)題涉及較少，并且站在保險(xiǎn)公司角度進(jìn)行分析，考慮的風(fēng)險(xiǎn)因素也會(huì)有所不同。因此文章的目的在于全面識(shí)別影響保險(xiǎn)公司運(yùn)營(yíng)大病保險(xiǎn)的各項(xiàng)風(fēng)險(xiǎn)因素，，形成風(fēng)險(xiǎn)評(píng)價(jià)體系，并嘗試用風(fēng)險(xiǎn)度量方法評(píng)價(jià)2013年試運(yùn)行狀態(tài)下的新農(nóng)合大病保險(xiǎn)風(fēng)險(xiǎn)狀況。 在新農(nóng)合大病保險(xiǎn)的時(shí)代背景和政策背景下，文章以全面風(fēng)險(xiǎn)管理理論為支撐，結(jié)合山東人保2013年新農(nóng)合大病保險(xiǎn)數(shù)據(jù)，挖掘現(xiàn)實(shí)工作和數(shù)據(jù)背后反映的問(wèn)題，初步識(shí)別新農(nóng)合大病保險(xiǎn)存在的內(nèi)部和外部風(fēng)險(xiǎn)因素。識(shí)別出的風(fēng)險(xiǎn)因素經(jīng)過(guò)保險(xiǎn)公司專業(yè)人員的修正和補(bǔ)充，建立了風(fēng)險(xiǎn)評(píng)價(jià)指標(biāo)體系。在風(fēng)險(xiǎn)評(píng)估環(huán)節(jié)中，考慮到大病保險(xiǎn)運(yùn)行時(shí)間較短，具體的風(fēng)險(xiǎn)數(shù)據(jù)難以掌握，有效數(shù)據(jù)時(shí)間跨度短也難以做回歸分析，因此本文選擇運(yùn)用AHP-模糊綜合評(píng)價(jià)模型為風(fēng)險(xiǎn)做評(píng)估。首先用層次分析法確定指標(biāo)權(quán)重，采用專家咨詢法，邀請(qǐng)高校保險(xiǎn)系教授、衛(wèi)生部門、保險(xiǎn)公司大病保險(xiǎn)管理部門以及醫(yī)院醫(yī)保報(bào)銷部門等4個(gè)單位的12名專家對(duì)風(fēng)險(xiǎn)因素進(jìn)行評(píng)估。隨后運(yùn)用模糊綜合評(píng)價(jià)測(cè)算指標(biāo)風(fēng)險(xiǎn)值。評(píng)價(jià)結(jié)果通過(guò)ABC法進(jìn)行分類，將指標(biāo)分成了“一般風(fēng)險(xiǎn)因素”、“主要風(fēng)險(xiǎn)因素”和“重要風(fēng)險(xiǎn)因素”，結(jié)果顯示大病保險(xiǎn)存在一定風(fēng)險(xiǎn)，但尚在可控范圍，各指標(biāo)中“政策管理”對(duì)大病風(fēng)險(xiǎn)影響程度最大，其次為“醫(yī)療需求風(fēng)險(xiǎn)”和“運(yùn)營(yíng)管理風(fēng)險(xiǎn)”�！盎痫L(fēng)險(xiǎn)”對(duì)整體風(fēng)險(xiǎn)影響較小。風(fēng)險(xiǎn)控制方面，依據(jù)控制的基本步驟、結(jié)合測(cè)算結(jié)果，有針對(duì)性的為每個(gè)風(fēng)險(xiǎn)主體提供風(fēng)險(xiǎn)控制建議。 評(píng)價(jià)結(jié)果能幫助決策者更全面認(rèn)知大病保險(xiǎn)存在的風(fēng)險(xiǎn)隱患，了解目前的風(fēng)險(xiǎn)情況，并能提供風(fēng)險(xiǎn)控制的側(cè)重方向。只有保證基金安全、控制醫(yī)療需求、加強(qiáng)運(yùn)營(yíng)管理、科學(xué)制定大病政策，才能確保大病保險(xiǎn)安全運(yùn)行，才能讓居民更大程度的享受醫(yī)療福利。
[Abstract]:From public medical treatment to universal medical insurance, the medical security system of our country has been continuously improved and deepened. At this stage, the level of basic medical security in China is relatively low, especially in the protection of major diseases. The individual burden of medical expenses is heavy. In order to improve the level of medical security for urban and rural residents, in 2012, the State issued the guidelines on carrying out serious illness Insurance for Urban and Rural residents, introducing a market mechanism and establishing a serious illness insurance system. Insurance companies also participate in the wave of health care reform as social managers. Urban and rural residents' serious illness insurance will soon be implemented throughout the country. Through comprehensive identification of risk factors and scientific risk assessment, policy makers can understand the risk situation facing serious illness insurance at this stage. It can also play a guiding role in adjusting the working methods of the policy-making organs, and has important significance for the steady operation of the insurance against serious illness. Reviewing the previous literature, the previous summary and research on social medical insurance mainly focused on fund risk, management model and other specific issues, and the overall identification and measurement of operational risks were less involved. Therefore, the purpose of this paper is to comprehensively identify the risk factors that affect the operation of the insurance company and form a risk evaluation system. The risk measurement method is used to evaluate the risk status of New Rural Cooperative Disease Insurance (NCMS) under the condition of trial operation in 2013. Under the background of the times and policies of the New Rural Cooperative Medical Insurance (NCMS), this paper, supported by the theory of comprehensive risk management, combined with the data of PICC in 2013, excavates the problems reflected in the actual work and the data. The internal and external risk factors of NCMS insurance are preliminarily identified. The identified risk factors are revised and supplemented by insurance company professionals, and a risk evaluation index system is established. Considering the short operating time of serious illness insurance, the difficulty in mastering specific risk data, and the difficulty in regression analysis for short time span of effective data, Therefore, this paper chooses the AHP- fuzzy comprehensive evaluation model to evaluate the risk. Firstly, the AHP is used to determine the index weight, and the expert consultation method is adopted to invite the professors of the insurance department of colleges and universities and the health department. The risk factors were evaluated by 12 experts from 4 units, including the insurance management department of the insurance company for serious illness and the medical insurance reimbursement department of the hospital. Then the index risk value was measured by fuzzy comprehensive evaluation. The evaluation results were classified by ABC method. The indexes are divided into "general risk factors", "main risk factors" and "important risk factors". The results show that there is a certain risk in the insurance of serious illness, but it is still under control, and "policy management" has the greatest influence on the risk of serious illness. Secondly, "Medical demand risk" and "Operation Management risk". "Fund risk" has little effect on the overall risk. In risk control, according to the basic steps of control, combined with the calculation results, Provide risk control advice for each risk subject. The evaluation results can help the decision makers to understand the hidden risks of the insurance, understand the current risk situation, and provide the direction of risk control. Only to ensure the security of the fund, control medical needs, strengthen the operation management, Only by making the serious illness policy scientifically can we ensure the safe operation of the serious illness insurance and let the residents enjoy the medical benefits to a greater extent.
【學(xué)位授予單位】：山東大學(xué)
【學(xué)位級(jí)別】：碩士
【學(xué)位授予年份】：2014
【分類號(hào)】：F323.89;F842.684;R197.1

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