本文選題：社會(huì)醫(yī)療保險(xiǎn) + 委托管理　； 參考：《西南財(cái)經(jīng)大學(xué)》2013年碩士論文

【摘要】：縱觀國際上的社會(huì)醫(yī)療保險(xiǎn)改革,采取政府引入“有管理的競爭”,積極推行社會(huì)醫(yī)療保險(xiǎn)領(lǐng)域的公共服務(wù)外包來降低成本、提升服務(wù)成為廣泛選擇。國外政府大多都通過政策鼓勵(lì)第三方部門參與到社會(huì)醫(yī)療保險(xiǎn)業(yè)務(wù)中來,實(shí)行管辦分離,制定法律框架,創(chuàng)建相應(yīng)的體制機(jī)制來約束和規(guī)范第三方受托機(jī)構(gòu)的競爭,營造與醫(yī)療費(fèi)用支出水平相適應(yīng)的質(zhì)量保障體系和效率提升機(jī)制。 《中共中央、國務(wù)院關(guān)于深化醫(yī)藥衛(wèi)生體制改革的意見》明確指出,深化醫(yī)藥衛(wèi)生體制改革的基本原則之一,是在保障公平的基礎(chǔ)上,統(tǒng)籌推進(jìn)效率的提高；注重發(fā)揮政府的主導(dǎo)作用,同時(shí)兼顧市場在資源配置中基礎(chǔ)性作用。切實(shí)轉(zhuǎn)變政府職能,強(qiáng)化政府在醫(yī)療衛(wèi)生制度、衛(wèi)生區(qū)域規(guī)劃、醫(yī)療衛(wèi)生資源投入、分配等醫(yī)療衛(wèi)生服務(wù)中的責(zé)任,充分體現(xiàn)我國醫(yī)療衛(wèi)生事業(yè)具有一定福利性的社會(huì)公益性特征,保障公平；與此同時(shí),政府也不能大包大攬,必須發(fā)揮社會(huì)主義市場經(jīng)濟(jì)體制的基礎(chǔ)性作用,廣泛地吸引社會(huì)力量參與,特別是社會(huì)資本、民間資本的投入,建立健全公平、合理、高效的市場競爭機(jī)制,實(shí)現(xiàn)社會(huì)醫(yī)療資源的優(yōu)化配置,提高社會(huì)醫(yī)療衛(wèi)生資源的運(yùn)營效率,更好的改善和服務(wù)民生,滿足人們?nèi)罕姸鄻踊�、多層次的醫(yī)療衛(wèi)生服務(wù)需求。針對(duì)目前我國的社會(huì)醫(yī)療保險(xiǎn)體系現(xiàn)狀,要進(jìn)一步擴(kuò)大社會(huì)醫(yī)療保險(xiǎn)覆蓋面、提高統(tǒng)籌層次、提高醫(yī)療保險(xiǎn)待遇水平、優(yōu)化異地結(jié)算支付等,同時(shí)在自愿、互利的基礎(chǔ)上,積極發(fā)展其他多種形式的補(bǔ)充醫(yī)療保險(xiǎn)和加快試點(diǎn)、逐步推廣大病保險(xiǎn)項(xiàng)目,建立健全更高水平的多層次的社會(huì)醫(yī)療保險(xiǎn)體系。以政府的有效監(jiān)管為原則、以社會(huì)醫(yī)療保險(xiǎn)基金的安全運(yùn)營為前提,積極倡導(dǎo)以政府購買方式擴(kuò)大社會(huì)醫(yī)療保險(xiǎn)服務(wù)供給,探索有資質(zhì)的社會(huì)力量參與、舉辦醫(yī)療衛(wèi)生機(jī)構(gòu)或者經(jīng)營管理部分社會(huì)醫(yī)療保險(xiǎn)服務(wù)項(xiàng)目。 隨著覆蓋城鄉(xiāng)居民的多層次醫(yī)療保險(xiǎn)體系的不斷建立和完善,社會(huì)醫(yī)療保險(xiǎn)的覆蓋面不斷擴(kuò)大、參保人數(shù)將不斷增加、社會(huì)醫(yī)療保險(xiǎn)基金的籌集和醫(yī)療費(fèi)用的支付規(guī)模不斷擴(kuò)大、社會(huì)醫(yī)療保險(xiǎn)的管理難度亦將不斷增加,勢必將對(duì)創(chuàng)新社會(huì)醫(yī)療保險(xiǎn)管理體制機(jī)制、提高醫(yī)療保險(xiǎn)管理服務(wù)水平提出更高的要求。立足于中國醫(yī)藥衛(wèi)生體制改革目標(biāo)和商業(yè)健康保險(xiǎn)的發(fā)展方向,積極探索社會(huì)醫(yī)療保險(xiǎn)管理引入競爭機(jī)制參與社會(huì)醫(yī)療保險(xiǎn)管理服務(wù)就顯得尤為重要,并具有相當(dāng)?shù)木o迫性。 本文即在上述背景下展開分析研究,旨在探討將大病醫(yī)療互助補(bǔ)充保險(xiǎn)業(yè)務(wù)委托保險(xiǎn)公司參與管理,而在基本醫(yī)療保險(xiǎn)項(xiàng)目中采取政府購買方式,同時(shí)在現(xiàn)有醫(yī)療衛(wèi)生資源條件下如何利用已有的費(fèi)用控制經(jīng)驗(yàn)、成果和手段,在新的各方制約關(guān)系框架下,提出切實(shí)可行的差異化的方式提高委托管理水平。全文分為5章,各章節(jié)的順序和主要內(nèi)容安排如下： 第一章為“導(dǎo)論”,簡述本文選題背景、研究意義,以及研究內(nèi)容、研究方法和研究思路,簡要概述了本文的主要?jiǎng)?chuàng)新之處及不足方面。 第二章為“社會(huì)醫(yī)療保險(xiǎn)委托管理的理論分析”,分析了社會(huì)醫(yī)療保險(xiǎn)委托管理在理論上可行性,主要介紹了社會(huì)福利多元化理論、公共服務(wù)市場化理論和合同外包。 第三章為“國內(nèi)外社會(huì)醫(yī)療保險(xiǎn)委托管理的現(xiàn)實(shí)選擇”,通過簡要地介紹世界上主要幾個(gè)國家的社會(huì)醫(yī)療保險(xiǎn)制度及大致的改革歷程,分析了美國、英國和荷蘭三國在面對(duì)醫(yī)療費(fèi)用支出快速增加的背景下所采取的社會(huì)醫(yī)療保險(xiǎn)改革措施及其蘊(yùn)含的政策啟示。例如美國積極鼓勵(lì)商業(yè)保險(xiǎn)公司參與各項(xiàng)醫(yī)療保險(xiǎn)業(yè)務(wù)的經(jīng)辦管理,荷蘭政府將醫(yī)療保險(xiǎn)業(yè)務(wù)全部交給保險(xiǎn)公司經(jīng)營并通過制定監(jiān)管體系來規(guī)范競爭,英國政府采取“內(nèi)部市場機(jī)制”來進(jìn)行醫(yī)療保險(xiǎn)改革。而我國尚未在全國范圍內(nèi)進(jìn)行統(tǒng)一的社會(huì)醫(yī)療保險(xiǎn)管理體制機(jī)制改革,但部分地方政府積極探索醫(yī)療保險(xiǎn)制度改革。在以湛江、德陽、廈門三地為代表的探索實(shí)踐中,通過引入競爭機(jī)制或者采取與第三方機(jī)構(gòu)合作,為進(jìn)一步深化社會(huì)醫(yī)療保險(xiǎn)管理機(jī)制改革提供了指導(dǎo)意義�？梢哉f,在社會(huì)醫(yī)療保險(xiǎn)領(lǐng)域引入管理式競爭已成為全球趨勢。 第四章為“社會(huì)醫(yī)療保險(xiǎn)委托管理的模式選擇和具體機(jī)制設(shè)計(jì)”,為了更好利用委托經(jīng)辦下的各方制約框架,特別是依據(jù)我國經(jīng)濟(jì)發(fā)展水平和醫(yī)療衛(wèi)生總支出中個(gè)人及家庭醫(yī)療衛(wèi)生支出仍占較大比重的狀況下,建議對(duì)大病互助補(bǔ)充保險(xiǎn)業(yè)務(wù)采用了最利于醫(yī)療費(fèi)用控制和能提供更好的醫(yī)療服務(wù)的委托管理模式選擇,而對(duì)基本醫(yī)療保險(xiǎn)業(yè)務(wù)的采取政府購買機(jī)制。 第五章為“結(jié)論與進(jìn)一步研究問題”,本章總結(jié)了前四章的研究,得出本文的研究結(jié)論,同時(shí)對(duì)社會(huì)醫(yī)療保險(xiǎn)委托管理的進(jìn)一步研究方向進(jìn)行了展望。
[Abstract]:In view of the international social medical insurance reform, the government introduced the "managed competition" and actively pursued the public service outsourcing in the field of social medical insurance to reduce the cost and promote the service to be widely chosen. Most of the foreign governments have adopted the policy to encourage the third departments to participate in the social medical insurance business. In addition, the legal framework is formulated and the corresponding institutional mechanism is created to restrict and standardize the competition between the third party trustees, and to create a quality assurance system and an efficiency improvement mechanism adapted to the level of medical expense expenditure.
"The Central Committee of the Communist Party of China, the State Council's opinion on deepening the reform of the medical and health system, clearly points out that one of the basic principles of deepening the reform of the medical and health system is to promote efficiency, on the basis of ensuring fairness, to give full play to the leading role of the government, and to take into account the basic role of the market in the allocation of resources. The government should strengthen the responsibility of the government in medical and health systems, health regional planning, medical and health resources input, distribution and other medical and health services, and fully reflect the social public welfare characteristics of the welfare of China's medical and health services and the protection of fairness. At the same time, the government can not wrap up a big package and have to play the socialist market economy. The basic role of the system is to attract the participation of social forces, especially the social capital, the input of the folk capital, the establishment of a fair, reasonable and efficient market competition mechanism, the optimal allocation of social medical resources, the improvement of the operational efficiency of the social medical and health resources, the better improvement and service of the people's livelihood, and the satisfaction of the diversity of the people. According to the present situation of the social medical insurance system in China, we should further expand the coverage of social medical insurance, improve the overall level, improve the treatment level of medical insurance, optimize the settlement and payment, and actively develop other forms of complementary medical care on the basis of voluntary and mutual benefit. Insurance and speeding up the pilot, gradually popularizing the big disease insurance project, establishing and improving the higher level and multi-level social medical insurance system, taking the effective supervision of the government as the principle, taking the safe operation of the social medical insurance fund as the premise, actively advocating the expansion of the social medical insurance service by the way of government purchase, and exploring the qualified society. To participate in the work, to organize medical and health institutions or to manage some social medical insurance services.
With the continuous establishment and improvement of the multi-level medical insurance system covering urban and rural residents, the coverage of social medical insurance is expanding, the number of insured people will increase continuously, the raising of the social medical insurance fund and the scale of medical expenses will continue to expand, and the difficulty of the management of social medical insurance will continue to increase. The medical insurance management system mechanism and the improvement of the medical insurance management service level put forward higher requirements. It is particularly important to explore the social medical insurance management and participate in the social medical insurance management service based on the target of Chinese medical and health system reform and the direction of the development of commercial health insurance. It is particularly important to introduce the social medical insurance management into the social medical insurance management service. When it comes to urgency.
The purpose of this paper is to explore the analysis and study under the above background. The purpose of this study is to discuss the participation of the insurance companies in the medical mutual assistance to the insurance companies, and to take the way of government purchase in the basic medical insurance projects, and how to use the existing cost control experience, results and means under the existing medical and health resources. Under the framework of restrictive relations, this paper puts forward a practical and feasible way to improve the management level of commission. The full text is divided into 5 chapters. The order and main contents of each chapter are as follows:
The first chapter is "Introduction", which describes the background of this topic, the significance of the research, the research content, research methods and research ideas, and briefly outlines the main innovations and shortcomings of this article.
The second chapter is "the theoretical analysis of the entrustment management of social medical insurance", and analyzes the theoretical feasibility of the social medical insurance entrustment management. It mainly introduces the theory of social welfare diversification, the theory of public service marketization and contract outsourcing.
The third chapter is "the realistic choice of the social medical insurance entrustment management at home and abroad". By briefly introducing the social medical insurance system and the general reform course of the major countries in the world, the social medical insurance reform in the United States, Britain and Holland in the context of the rapid increase of medical expense expenditure is analyzed. Measures and their implications. For example, the United States actively encourages the Business insurance company to participate in the management of the medical insurance business. The government of Holland has all the medical insurance business run to the insurance company and regulate the competition through the establishment of a regulatory system. The British government adopts the "internal market mechanism" to carry out medical insurance reform. But China has not yet carried out a unified reform of the system and mechanism of social medical insurance management throughout the country, but some local governments actively explore the reform of the medical insurance system. In the exploration and practice of the three places in Zhanjiang, Deyang and Xiamen, through the introduction of the competition mechanism or the cooperation with the third party organizations, the social medicine is further deepened. It can be said that the introduction of management competition in the field of social medical insurance has become a global trend.
The fourth chapter is "the mode selection and the specific mechanism design of the entrustment management of social medical insurance". In order to make better use of the restrictive framework of the parties under the entrustment, in particular, it is suggested that the mutual assistance to large diseases should be supplemented under the condition that our country's economic development level and the medical and health expenditure of the general medical and health expenditure still account for a large proportion of the medical and health expenditure. The insurance business adopts the choice of principal management model which is most conducive to the control of medical expenses and can provide better medical services, and the government purchase mechanism for the basic medical insurance business.
The fifth chapter is "the conclusion and further research problem". This chapter summarizes the research in the first four chapters, and draws the conclusions of this paper. At the same time, it looks forward to the further research direction of the social medical insurance entrustment management.

【學(xué)位授予單位】：西南財(cái)經(jīng)大學(xué)
【學(xué)位級(jí)別】：碩士
【學(xué)位授予年份】：2013
【分類號(hào)】：F842.684

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