本文選題：基本醫(yī)療保險(xiǎn)一體化 + 籌資模式　； 參考：《南開大學(xué)》2014年博士論文

【摘要】：本文是一個(gè)關(guān)于基本醫(yī)療保險(xiǎn)一體化制度的探索性研究,通過相關(guān)的理論研究、政策分析與經(jīng)驗(yàn)研究,將社會(huì)政策分析與規(guī)范經(jīng)濟(jì)學(xué)研究運(yùn)用到基本醫(yī)療保險(xiǎn)制度領(lǐng)域的研究。論文將卡爾·波蘭尼的“嵌入性”理論作為基本醫(yī)療保險(xiǎn)一體化制度的分析框架之一,梳理了基本醫(yī)療保險(xiǎn)一體化制度可能的理論基礎(chǔ),結(jié)合經(jīng)濟(jì)學(xué)的分析視角,論證了基本醫(yī)療保險(xiǎn)一體化制度的核心要素及其制度框架,在此基礎(chǔ)上,論文圍繞著作為基本醫(yī)療保險(xiǎn)制度體系的三個(gè)主體即醫(yī)療保險(xiǎn)機(jī)構(gòu)、被保險(xiǎn)人、醫(yī)療服務(wù)提供者之間的本質(zhì)關(guān)系及其內(nèi)在矛盾,借助二手文獻(xiàn)資料的分析與相關(guān)數(shù)據(jù),闡釋了我國現(xiàn)行基本醫(yī)療保險(xiǎn)制度在改革過程中面臨的問題及其深層次的影響因素,并借鑒英國、美國及加拿大三國醫(yī)療保險(xiǎn)一體化的制度框架與路徑,主要從籌資模式、醫(yī)療費(fèi)用支付方式及醫(yī)療保險(xiǎn)經(jīng)辦機(jī)構(gòu)三個(gè)方面提出建構(gòu)基本醫(yī)療保險(xiǎn)一體化制度的政策建議。通過相關(guān)的理論分析與經(jīng)驗(yàn)考察,本文的研究發(fā)現(xiàn)如下： 第一,我國已經(jīng)建立以城鎮(zhèn)職工基本醫(yī)療保險(xiǎn)制度、城鎮(zhèn)居民基本醫(yī)療保險(xiǎn)制度和新型農(nóng)村合作醫(yī)療制度為主體的基本醫(yī)療保險(xiǎn)制度體系,現(xiàn)行基本醫(yī)療保險(xiǎn)制度體系的三大主體制度分屬不同的部門管理,各自獨(dú)立封閉運(yùn)行,并且三者的籌資水平、保障水平差異較大,籌資公平性較差,呈明顯“碎片化”特征。 第二,在社會(huì)政策學(xué)層面,論證了卡爾·波蘭尼的“嵌入性”理論作為基本醫(yī)療保險(xiǎn)一體化制度的社會(huì)政策學(xué)分析框架之一,提出現(xiàn)代社會(huì)存在著“市場(chǎng)-社會(huì)”之間的吊詭關(guān)系：虛擬商品與社會(huì)自我保護(hù)運(yùn)動(dòng)之間的內(nèi)在矛盾。以公民身份作為個(gè)人享受社會(huì)權(quán)利的標(biāo)準(zhǔn)可使勞動(dòng)力去商品化并作為一種社會(huì)政策的理論指向,這種理論指向是突破“市場(chǎng)-社會(huì)”吊詭關(guān)系的路徑和選擇,并成為社會(huì)政策研究的邏輯起點(diǎn)�；踞t(yī)療保險(xiǎn)一體化制度的理論基礎(chǔ)正是基于在“市場(chǎng)”必然嵌入“社會(huì)”的前提下,以社會(huì)公民的權(quán)利為資格使得每個(gè)公民在處于任何社會(huì)條件下都能公平地獲得基本醫(yī)療保險(xiǎn)。 第三,基本醫(yī)療保險(xiǎn)制度的經(jīng)濟(jì)學(xué)分析顯示,由于醫(yī)療市場(chǎng)的不完性以及個(gè)人的有限理性使得健康消費(fèi)會(huì)產(chǎn)生外部性,當(dāng)消費(fèi)者的收入一定時(shí),無論消費(fèi)者是否對(duì)健康進(jìn)行消費(fèi)或投資,都會(huì)產(chǎn)生福利上的凈損失。因此,消費(fèi)者所產(chǎn)生的福利凈損失就只能由政府提供的基本醫(yī)療保險(xiǎn)制度來化解和彌補(bǔ)。同時(shí),健康稅的分配效應(yīng)表明,對(duì)高收入者征稅與對(duì)低收入者進(jìn)行收入再分配是對(duì)市場(chǎng)扭曲程度最小的辦法。高收入者的福利減少被低收入者福利增加抵消了一部分,從而使整體福利的凈損失不至于太大。 第四,對(duì)英國、美國、加拿大三國醫(yī)療保險(xiǎn)制度的比較分析表明,作為商業(yè)醫(yī)療保險(xiǎn)型的美國與全民醫(yī)療服務(wù)模式的英國及加拿大在醫(yī)療保險(xiǎn)制度的建構(gòu)、內(nèi)容的設(shè)計(jì)以及與之相關(guān)的價(jià)值觀存在著較大差異,但就三個(gè)國家的籌資模式而言,美國公立醫(yī)療保險(xiǎn)體系的籌資模式與英國、加拿大兩國的籌資模式是高度相似的,即以一般稅作為籌資渠道及來源。因此,在這個(gè)意義上說,通過一般稅收的籌資模式是構(gòu)建基本醫(yī)療保險(xiǎn)一體化的最佳籌資路徑。 第五,基于以上分析,基本醫(yī)療保險(xiǎn)一體化制度的建構(gòu)基于以下幾點(diǎn)：第 作為醫(yī)療市場(chǎng)的第三方支付者,以成功的價(jià)格談判機(jī)制和合理的費(fèi)用支付方式有效地平衡醫(yī)、患、保三者之間的關(guān)系；第二,作為健康風(fēng)險(xiǎn)的集中者,使所有消費(fèi)者都具有獲得健康的平等權(quán)利；第三,作為醫(yī)療市場(chǎng)不完全性的彌補(bǔ)者,有效彌補(bǔ)個(gè)人健康消費(fèi)的有限理性,并具有對(duì)低收入者和高收入者的再分配效應(yīng)。由于健康風(fēng)險(xiǎn)與老年風(fēng)險(xiǎn)存在較大的差異,使得醫(yī)療保險(xiǎn)的制度安排不能簡(jiǎn)單模仿和照搬養(yǎng)老保險(xiǎn)制度。因此,基本醫(yī)療保險(xiǎn)的籌資機(jī)制應(yīng)該與養(yǎng)老保險(xiǎn)獨(dú)立開來,對(duì)工薪進(jìn)行課稅作為籌資方式,采用以總額預(yù)付制為主的費(fèi)用支付方式并設(shè)立統(tǒng)一的醫(yī)療保險(xiǎn)經(jīng)辦機(jī)構(gòu)負(fù)責(zé)資金配置以及向醫(yī)療服務(wù)機(jī)構(gòu)付費(fèi)和價(jià)格談判,從而實(shí)現(xiàn)基本醫(yī)療保險(xiǎn)一體化的制度建構(gòu)。
[Abstract]:This article is an exploratory study of the integration of basic medical insurance. Through the relevant theoretical research, policy analysis and empirical research, the research of social policy analysis and normative economics is applied to the basic medical insurance system. The thesis uses Karl Polanyi's "embeddedness" theory as the basic medical insurance. One of the analytical frameworks of the integration system, combing the possible theoretical basis of the basic medical insurance integration system, and combining with the perspective of economic analysis, demonstrated the core elements and the institutional framework of the basic medical insurance integration system. On this basis, the paper revolves around the three main bodies of the basic medical insurance system, namely medical treatment. The essential relations and internal contradictions between the insurance institutions, the insured and the medical service providers, with the help of the analysis and relevant data of the second-hand literature, explain the problems faced by the current basic medical insurance system in China and the deep influence factors in the process of reform, and draw on the medical insurance of the three countries in the United Kingdom, the United States and Canada. The integrated system framework and path, mainly from three aspects of financing mode, medical expense payment method and medical insurance agency, put forward the policy suggestions for the construction of the basic medical insurance integration system.
First, China has established the basic medical insurance system based on the basic medical insurance system for urban workers, the basic medical insurance system of urban residents and the new rural cooperative medical system. The three main body systems of the current basic medical insurance system belong to different department management, respectively, independent and closed operation, and three parties. The level of financing, the level of protection is quite different, and the fairness of financing is poor, showing a "fragmentation" feature.
Second, at the social policy level, it demonstrates Karl Polanyi's "embeddedness" theory as one of the social policy analysis frameworks of the basic medical insurance integration system, and puts forward the paradox between the "market society" in modern society: the internal contradiction between the virtual goods and the social self-protection movement. As the standard of personal enjoyment of social rights, identity can make the labour force commercialized and point to the theory of a social policy. This theory points to a path and choice to break through the paradox of "market society", and is the logical starting point for the research of social policy. The theoretical basis of the basic medical insurance system is based on the theory of the theory The "market" must be embedded in the "society", with the rights of social citizens as a qualification for every citizen to be able to obtain a fair basic medical insurance under any social condition.
Third, the economic analysis of the basic medical insurance system shows that, because of the lack of medical market and the limited rationality of the individual, the healthy consumption will produce externality. When the consumer's income is certain, the net loss of welfare is caused by whether the consumer is consuming or investing in health. At the same time, the distribution effect of health tax shows that the tax on high income persons and the redistribution of income to the low-income people are the least distortions to the market. The welfare reduction of the high income is partly offset by the increase in the welfare of the low income. The net loss of the overall welfare will not be too large.
Fourth, a comparative analysis of the medical insurance system in Britain, the United States and Canada shows that there are great differences in the construction of the medical insurance system, the design of the medical insurance system, the design of the content and the values associated with the British and Canadian model of the commercial medical insurance and the national medical service model of the United States and the whole nation, but on the financing mode of the three countries, In the United States, the financing model of the American public health insurance system is highly similar to that in Britain and Canada. That is, the general tax is used as a fund-raising channel and source. Therefore, in this sense, the financing mode of general tax is the best way to build the basic medical insurance.
Fifth, based on the above analysis, the construction of the basic medical insurance integration system is based on the following points:
As a third party payer in the medical market, the relationship between doctors, patients and the three parties is effectively balanced by a successful price negotiation mechanism and a reasonable cost payment method; second, as a concentration of health risks, all consumers have the equal right to gain health; third, as a remedy for the incompleteness of the medical market, there are It makes up for the limited rationality of personal health consumption, and has the redistribution effect on the low income and the high income people. Because of the great difference between the health risk and the elderly risk, the institutional arrangement of medical insurance can not simply imitate and copy the pension insurance system. Therefore, the financing mechanism of the basic medical insurance should be independent of the pension insurance. As a fund-raising method, the salary payment method based on total prepayment system and the establishment of a unified medical insurance agency responsible for the allocation of funds and the payment and price negotiation to the medical service institutions are set up to realize the system construction of the integration of basic medical insurance.
【學(xué)位授予單位】：南開大學(xué)
【學(xué)位級(jí)別】：博士
【學(xué)位授予年份】：2014
【分類號(hào)】：F842.684;R197.1

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