本文選題：醫(yī)療責任保險　切入點：風險管理　出處：《復旦大學》2014年碩士論文　論文類型：學位論文

【摘要】：一、研究背景隨著國內醫(yī)療糾紛的發(fā)生頻率越來越高,如何有效化解醫(yī)療風險,加強醫(yī)療風險管理,緩解醫(yī)患矛盾已成為政府關注的重點問題。上海從2002年10月開始進行醫(yī)療責任保險的探索,并初步建立了有效的醫(yī)療風險分擔機制。但是國內醫(yī)療責任保險尚處于起步階段,發(fā)展還十分不成熟,面臨較多的發(fā)展障礙和存在比較突出的問題,現(xiàn)行醫(yī)療責任保險在建立風險共擔、激勵和約束機制,構建和諧醫(yī)患關系,保證醫(yī)患雙方合法權益中的作用未能明顯體現(xiàn)。在此背景下,本研究對上海市醫(yī)療責任保險運行模式存在問題及完善建議進行探討。二、研究目的和方法1、研究目的本研究擬通過訪談、調查等方法明確上海醫(yī)療責任保險的運行現(xiàn)狀、特征和存在問題,并結合醫(yī)改要求提出上海醫(yī)療責任保險的改善策略。2、研究方法在研究中,綜合利用文獻分析法、二手資料收集與分析、現(xiàn)況調查和關鍵知情人訪談,收集研究所需資料。通過查閱國內外有關醫(yī)療責任保險管理模式的成功經(jīng)驗和做法,為上海醫(yī)療責任保險模式提供借鑒；通過收集上海實行醫(yī)療責任保險10年的運行數(shù)據(jù)資料,對其發(fā)展、運行狀況等情況進行統(tǒng)計分析；通過調查問卷和訪談,了解醫(yī)院對上海醫(yī)療責任保險的認知及需求建議,如醫(yī)院是否需要購買醫(yī)療責任保險,醫(yī)療責任保險的管理模式,醫(yī)療責任保險保費的合理性,對分擔醫(yī)療糾紛賠償?shù)挠行?理賠程序,上海醫(yī)療責任保險存在問題的原因,醫(yī)院對醫(yī)療責任保險的建議等。三、研究結果本次研究發(fā)現(xiàn),國外的醫(yī)療責任保險主要有三種模式：商業(yè)保險為主體、依托行業(yè)或機構的互助保險、以及以國家財政保障為主體的醫(yī)療責任保險模式。三種模式的形成與發(fā)展與不同國家的衛(wèi)生系統(tǒng)、籌資系統(tǒng)、文化習俗等都有關系。國內的醫(yī)療責任保險發(fā)展歷史相對較短,較典型的有擴大責任范疇的北京醫(yī)療責任保險模式、強調個人責任和風險分擔的深圳模式,以及強調市場競爭機制的寧波公保體模式。三者各有優(yōu)缺點。上海作為國內最早探索醫(yī)療責任險的地區(qū),當前醫(yī)療責任保險發(fā)展緩慢甚至出現(xiàn)倒退,表現(xiàn)為醫(yī)院投保率下降和保險公司積極性不高等。調查發(fā)現(xiàn),2011年樣本中的投保率雖然高達95%,但超過一半以上的三級醫(yī)院不愿投保；一、二、三級醫(yī)院的年均保費介于8-44萬元間；7成以上樣本醫(yī)院認為醫(yī)療責任保險至少能部分分擔醫(yī)療事故或醫(yī)療糾紛造成的損失,但醫(yī)療責任保險的保費設置與保費調整缺乏依據(jù)；而且理賠措施繁瑣,服務亟待提高,大多數(shù)三級醫(yī)院在這方面的不滿尤為明顯(與一二級醫(yī)院的差異有統(tǒng)計學意義)；調查對象認為,供方的市場壟斷、缺乏競爭是導致服務質量較差、索賠困難的主要原因。對醫(yī)療責任保險的需求調查發(fā)現(xiàn),不到1%的醫(yī)院認為醫(yī)療風險應自行解決,近一半醫(yī)院認為此類風險應由政府或社會協(xié)同解決,且其籌資可考慮從財政撥款中撥付。保險覆蓋對象應從醫(yī)院拓寬至醫(yī)生個人,這可以擴大保險對象,體現(xiàn)大數(shù)法則和增強風險共濟能力。從籌資角度,籌資水平則應該考慮與其不同�？啤⒉煌瑐�體服務的風險掛鉤。從管理模式上,近8成調查對象認為此類保險應該是非營利的,且最好由政府主導(62.4%)。研究認為當前上海市醫(yī)療責任險運行中的問題根源在于：1)從投保對象上看,以機構為主的投保對象過少,無法起到強有力的風險共濟作用,這在三級醫(yī)院中尤為明顯：2)從保費的設置上看,保費制定和調整缺乏規(guī)范,引起保險對象的不滿；3)從保險管理上看,市場機制不明確,缺乏競爭：4)從風險類型上看,忽視了醫(yī)院在處理醫(yī)患矛盾和醫(yī)療糾紛時的非貨幣成本,后續(xù)的服務沒有對此類風險進行管理和分擔,這可能是三級醫(yī)院不愿購買保險的最主要原因之一。四、討論與建議研究提出如下建議：1)醫(yī)療責任保險有分散醫(yī)療風險,保障醫(yī)患雙方合法權益,構建和諧醫(yī)患關系,維護正常醫(yī)療秩序,保障醫(yī)學科學健康發(fā)展的巨大作用,上海要在新一輪深化醫(yī)藥衛(wèi)生體制改革,健全法律法規(guī)建設,保證醫(yī)療行業(yè)公益性的前提下,及時完善相關醫(yī)療責任保險制度。通過政府支持,完善相關法律法規(guī),實行強制醫(yī)療責任保險；2)其次要科學厘定保險費率,完善醫(yī)療風險評估防范機制；3)同時要開放市場,引入競爭機制,豐富醫(yī)療責任保險產(chǎn)品；4)最后充分發(fā)揮第三方專業(yè)機構作用,將醫(yī)療糾紛調解與醫(yī)療責任保險有效銜接,減少醫(yī)院在糾紛處理中的時間和精力投入,加強對此類非貨幣醫(yī)療風險的管理緩解醫(yī)患矛盾,保障各方合法權益。
[Abstract]:A background with the domestic medical disputes are more frequent, how to effectively resolve the medical risk, strengthen the management of medical risk, ease the contradiction between doctors and patients has become the focus of concern of the government. To explore the start of the Shanghai medical liability insurance from October 2002, and established the effective medical risk sharing mechanism. But the domestic medical liability insurance is still in the initial stage, development is not mature yet, faced more obstacles to development and the problems existing in the establishment of medical liability insurance, risk sharing, incentive and restraint mechanisms, building a harmonious doctor-patient relationship, guarantee the legitimate rights and interests of both doctors and patients in the not obvious. Under this background, the research questions and suggestions to explore the operation mode of medical liability insurance in Shanghai city. Two, the research purpose and method of 1 research purposes in this research intends to visit Talk, investigation methods clear Shanghai operation of medical liability insurance, characteristics and existing problems, and combined with the requirements of health care reform put forward the improvement strategy of Shanghai.2 medical liability insurance, research methods in the study, the comprehensive use of literature analysis, collection and analysis of secondary data, current situation survey and key informant interviews, collect research required data. Through the successful experiences and practices at home and abroad about the medical liability insurance management mode, provide reference for Shanghai medical liability insurance model; the data operation data of 10 years of medical liability insurance through the collection of Shanghai, the development situation, the status of statistical analysis; through questionnaires and interviews, suggestions on cognition and demand Shanghai medical liability insurance to hospitals, such as hospitals need to purchase medical liability insurance, medical liability insurance management mode, medical liability insurance premiums The rationality, validity of claims, sharing medical malpractice compensation program, Shanghai medical liability insurance problems, the hospital of the medical liability insurance proposal. Three, the study found that the results of the study, medical liability insurance abroad mainly has three modes: commercial insurance as the main body, relying on industry or organization mutual insurance, as well as the national financial security as the main mode of medical liability insurance. The three modes of formation and development of different countries with the health system, financing system, are related to cultural practices. The domestic medical liability insurance development history is relatively short, the typical expanded responsibility category of Beijing medical liability insurance model, emphasis on personal responsibility and risk sharing mode of Shenzhen, and stressed that the market competition mechanism of Ningbo right mode. The three have different advantages and disadvantages. Shanghai as the earliest exploration of medical responsibility Any insurance area, the development of medical liability insurance is slow and even reverse, as the hospital insurance rate decline and the Insurance Company enthusiasm is not high. The survey found that in 2011 in the sample although the insurance rate is as high as 95%, but more than half of the three hospitals than the insured; two, three, the average annual premium level hospital between 8-44 yuan; more than 7 sample hospitals that medical liability insurance can at least share of medical malpractice or medical disputes caused by the loss, but the medical liability insurance premium and premium adjustment based on the lack of measures; and claims service needs to be improved, most complicated, three hospitals in this area is particularly obvious dissatisfaction (statistically the significance of differences and one or two grade hospitals); respondents believe, the market monopoly, lack of competition leads to poor quality of service, the main reason of medical liability claims difficult. The survey found the demand for insurance, less than 1% of the hospital that medical risk should be resolved, nearly half of the hospital that the government or society should solve such risks, and the financing can be allocated from the financial allocation. The object should be to broaden the coverage of hospital doctors, it can expand the insurance object, reflecting the law of large numbers and enhanced the risk of Masonic ability. From the financing point of view, the level of financing should be considered with different specialties, individual risk linked services. From the management model, nearly 8 of respondents believe that such insurance should be non-profit, and best led by the government (62.4%). The study believes that the current Shanghai City medical liability insurance in the operation the root of the problem: 1) from the insured object, insurance object is too small in the main body, can not play the role of Freemasonry strong risk, which is especially obvious in the hospitals of Grade Three: 2) from Paul The fee on the set, the premium formulation and adjustment of the lack of standard, cause insurance object dissatisfaction; 3) from the insurance management point of view, the market mechanism is not clear, the lack of competition: 4) from the risk type, ignoring the hospital in dealing with doctor-patient conflicts and medical disputes when non monetary costs, not on the follow-up service this kind of risk management and sharing, this may be the main reason for three hospitals to purchase insurance to one. Four, put forward the following suggestions on discussion and suggestions: 1) medical liability insurance with scattered medical risks, protect the legitimate rights and interests of both doctors and patients, to build a harmonious doctor-patient relationship, to maintain normal medical order, a huge role to guarantee the healthy development of medicine science, to Shanghai in the new round of deepening the reform of the medical and health system, improve the construction of laws and regulations, guarantee the public medical industry, improve the related medical liability insurance through the system. The support of the government, improve the relevant laws and regulations, the implementation of compulsory medical liability insurance; 2) next to the scientific premium rates, improve the medical risk assessment and prevention mechanism; 3) to open up the market, the introduction of competition mechanism, enrich the medical liability insurance products; 4) finally give full play to the role of the third party professional organizations, the medical dispute mediation and the medical liability insurance effectively, reduce the hospital in the disputes in time and effort, to strengthen the medical risk management of non monetary easing the doctor-patient conflicts, protect the legitimate rights and interests of all parties.

【學位授予單位】：復旦大學
【學位級別】：碩士
【學位授予年份】：2014
【分類號】：R197.1;F842.684

【二級參考文獻】

相關期刊論文 前2條

1 朱銘來;焦峰;;醫(yī)療責任保險制度的國際比較研究[J];保險研究;2008年07期

2 李守全;;引入人民調解化解醫(yī)患糾紛的實踐和思考[J];上海醫(yī)學;2008年10期

，

本文編號：1612709