【摘要】：國外對社會醫(yī)療保險委托經(jīng)辦管理研究已經(jīng)有很長一段時間,像美國、德國、英國等國家已經(jīng)形成了各自發(fā)展模式。研究表明,在社會醫(yī)療保險中引入委托管理可以提高其運行效率、節(jié)省成本等。我國很多地區(qū)也在進行社會醫(yī)療保險委托經(jīng)辦管理的實踐,而且取得了一定的成績,但是也存在許多問題,例如,缺少理論支持、運行機制不成熟等。針對這些問題,筆者將詳細(xì)闡述社會醫(yī)療保險發(fā)達國家的做法,總結(jié)其經(jīng)驗教訓(xùn),然后系統(tǒng)闡述我國社會醫(yī)療保險委托經(jīng)辦管理的實踐情況,研究其存在的問題,并提出可行性建議。本文具體研究思路和邏輯結(jié)構(gòu)如下： 第一章,緒論部分。筆者首先闡述了本文的研究背景、意義、目的、內(nèi)容和方法,綜述了社會醫(yī)療保險委托管理的理論基礎(chǔ)以及國內(nèi)外有關(guān)社保委托管理的文獻,并指出了本文的貢獻以及不足之處。 第二章是社會醫(yī)療保險委托經(jīng)辦管理的國際經(jīng)驗及啟示。社會醫(yī)療保險的發(fā)展是一個過程,在很多國外社會醫(yī)療保險發(fā)達的國家中,它們針對自己的國情采取了各種措施來解決社會醫(yī)療保險中存在的問題。例如在美國,通過把商業(yè)保險機構(gòu)引入到社會醫(yī)療保障體系中,形成了一種行之有效的“管理式醫(yī)療模式”,把第三方管理引入到社會醫(yī)療保險管理中；在德國,政府部門與社會團體加強對醫(yī)療保險運行的監(jiān)管,通過“管辦分離”和“第三方付費”的方式來提高社會醫(yī)療保險效率,這本質(zhì)上是把第三方引入到社會醫(yī)療保險服務(wù)中,這取得了很大的成效；荷蘭的HIA模式也是社會醫(yī)療保險改革成功的成果,荷蘭政府鼓勵多家商業(yè)保險公司參與社會醫(yī)療保險產(chǎn)品的開發(fā)和銷售,投保人可以根據(jù)自己的情況選擇所要投的保險公司,競爭是荷蘭HIA的核心思想,荷蘭的社會醫(yī)療保險的委托經(jīng)辦管理主要形式也是實行“有管理的競爭”模式；最后,在英國社會醫(yī)療保險體制改革中,政府部門把市場競爭和“內(nèi)部市場化改革”引入到NHS體系,以社保基金為中介來優(yōu)化委托經(jīng)辦管理,其改革也是成功的。這些國家的改革各有各的特點,但它們的改革都有一個共同點,那就是,把市場競爭機制和委托經(jīng)辦管理模式引入到社會醫(yī)療保險體系中。 第三章,我國社會醫(yī)療保險委托經(jīng)辦管理模式及總結(jié)。我國社會醫(yī)療體制改革始于1994年,經(jīng)過近20年的變革,我國社保體制取得了明顯的進步。在社會醫(yī)療保險委托經(jīng)辦模式上,我國很多地方根據(jù)自身情況,敢于創(chuàng)新、大膽變革,逐步形成了一些獨具特色的社會醫(yī)療保險模式。主要有：“基于大病補充醫(yī)療式的,把大病補充業(yè)務(wù)委托給商業(yè)保險公司經(jīng)營”的廈門模式；“政府出資購買中介服務(wù),保險公司負(fù)責(zé)新農(nóng)合業(yè)務(wù)管理”的“江陰模式”和“新鄉(xiāng)模式”；“把基本醫(yī)療保險和補充醫(yī)療保險全面委托給商業(yè)保險公司管理”的“湛江模式”等。這些模式的委托管理形式多樣,但是總體來說,他們屬于兩種模式,一種是“基金管理型模式”,保險公司只收取一定保費,不承擔(dān)風(fēng)險；另一種是有保險公司介入的,保險公司以合同的形式參與醫(yī)療保險經(jīng)營的模式,保險公司自主經(jīng)營,自負(fù)盈虧,這種模式被稱為“保險合同型模式”。這些模式效果顯著,例如,社保參保率大幅提升、降低了社保運營成本、提高了辦事效率、有利于對社�；顒拥谋O(jiān)管以及促進商業(yè)保險公司發(fā)展等。 第四章,我國社會醫(yī)療保險委托經(jīng)辦管理存在的問題及未來發(fā)展建議。雖然我國發(fā)展出“基金管理型模式”和“保險合同型模式”兩種社會醫(yī)療保險委托經(jīng)辦模式,但是,這兩種模式發(fā)展還處于初步階段,存在不少缺陷。本章主要研究這兩種模式存在的問題及未來發(fā)展建議。首先是“基金管理型模式”,其存在的主要問題有：缺乏市場競爭,市場競爭主體少；社�；鹨�(guī)模小,社保資源沒有得到優(yōu)化配置；對社�；疬\營管理缺乏監(jiān)管機制。其未來發(fā)展建議有：1、實行“有管理的競爭”,在鼓勵競爭的同時,進行適度的管理,讓一些優(yōu)質(zhì)的中小保險公司也能夠參與到社會醫(yī)療保險的管理中。2、放開社保業(yè)務(wù)給商業(yè)保險公司管理。3、擴大委托管理試點,加大成功經(jīng)驗的推廣。4、加快社保委托管理專門性規(guī)范文件的制定,無規(guī)矩不成方圓,如果不建立我國社會醫(yī)療保險委托管理的規(guī)范性文件,我國在這方面的改革可能會走向“無政府”狀態(tài)。其次是“保險合同型模式”,其存在主要問題有：商業(yè)保險公司參與度低；政府角色不明確,政策穩(wěn)定性低；缺乏競爭性的社�；鹬黧w。其未來發(fā)展建議有：1、鼓勵商業(yè)保險公司開發(fā)醫(yī)療保障產(chǎn)品,從國際經(jīng)驗看,在社會醫(yī)療保險基金管理主體之間引入競爭機制已經(jīng)取得了顯著成效。2、加強對商業(yè)保險公司經(jīng)辦社保業(yè)務(wù)的監(jiān)管,加強對商業(yè)保險公司經(jīng)辦業(yè)務(wù)的監(jiān)管除了依靠政府強有力的行政權(quán)之外,還需要制定經(jīng)辦業(yè)務(wù)的相關(guān)法律,加強商業(yè)保險公司行業(yè)內(nèi)的相互監(jiān)管,而且媒體監(jiān)督也是一個重要方面。3、明確政府定位,鼓勵商業(yè)保險公司參與管理。 本文的貢獻主要有：1、本文系統(tǒng)歸納了美國、德國、荷蘭以及英國的社會醫(yī)療保險委托經(jīng)辦管理的經(jīng)驗,對這幾個國家發(fā)展模式進行了比較、分析。2、本文詳細(xì)闡述了廈門、新鄉(xiāng)、江陰以及湛江四地的社會醫(yī)療保險委托經(jīng)辦模式,并把它們歸于“基金管理型”和“保險合同型”兩種模式。3、最后,筆者總結(jié)了我國社會醫(yī)療保險委托管理取得的成就、分析其存在的問題,并提出了一些未來發(fā)展建議。 本文的不足之處有：1、由于時間和能力有限,在國內(nèi)外社會醫(yī)療保險模式分析時,沒能做出很好的總結(jié)和分析。2、由于數(shù)據(jù)獲取難度比較大,研究所需的很多數(shù)據(jù)都沒有收集到,這影響了文章的實證性。3、筆者沒有實地了解國內(nèi)外社保委托經(jīng)辦管理情況,實踐經(jīng)驗匱乏,文章所提出的幾個觀點和建議顯得蒼白無力,尚需經(jīng)歷時間的歷練和實踐的考驗。
[Abstract]:It has been a long time for foreign countries to study the entrusted management of social medical insurance, such as the United States, Germany, the United Kingdom and other countries have formed their own development model. In view of these problems, the author will elaborate the practices of developed countries in social medical insurance, summarize their experiences and lessons, and then systematically expound the entrusted management of social medical insurance in China. Practice, study the existing problems and put forward feasible suggestions. The specific research ideas and logical structure are as follows:
The first chapter, the introduction part, the author first elaborated the research background, significance, purpose, content and method of this paper, summarized the theoretical basis of social medical insurance entrusted management and domestic and foreign literature on social security entrusted management, and pointed out the contribution and shortcomings of this paper.
The second chapter is the international experience and Enlightenment of the entrusted management of social medical insurance. The development of social medical insurance is a process. In many developed countries, they have taken various measures to solve the problems of social medical insurance according to their own national conditions. Institutions have been introduced into the social medical security system, forming an effective "managerial medical model" to introduce the third-party management into the management of social medical insurance; in Germany, government departments and social organizations have strengthened the supervision of the operation of medical insurance, through the "separation of management and management" and "third-party payment" to improve. The efficiency of social medical insurance is essentially the introduction of the third party into social medical insurance services, which has achieved great results; the Dutch HIA model is also the success of social medical insurance reform results, the Dutch government encourages a number of commercial insurance companies to participate in the development and marketing of social medical insurance products, the insured can according to their own. Competition is the core idea of the Netherlands HIA, and the principal form of the management of the social medical insurance in the Netherlands is the "managed competition" model. Finally, in the reform of the British social medical insurance system, the government introduced the market competition and the "internal market reform" into the N. The reform of HS system, which uses social security fund as the intermediary to optimize entrusted management, is also successful. The reforms in these countries have their own characteristics, but their reforms have one thing in common, that is, introducing market competition mechanism and entrusted management mode into the social medical insurance system.
The third chapter is the management model and summary of the entrusted management of social medical insurance in China.The reform of social medical system in China began in 1994.After nearly 20 years of reform, the social security system in China has made remarkable progress.In the mode of entrusted management of social medical insurance, many places in China dare to innovate and change boldly according to their own conditions, and gradually take shape. There are some unique social medical insurance models, such as the Xiamen model of "entrusting the supplementary business of serious illness to commercial insurance companies based on the supplementary medical treatment of serious illness"; the Jiangyin model and the Xinxiang model of "government-funded purchase of intermediary services, insurance companies responsible for the management of the new rural cooperative medical service"; and the "Ba" The Zhanjiang mode of entrusting basic medical insurance and supplementary medical insurance to commercial insurance company is various, but generally speaking, they belong to two modes: one is fund management mode, the insurance company only charges a certain premium and does not take risks; the other is insured. Insurance companies intervene, insurance companies participate in the form of contracts in the medical insurance business model, insurance companies operate independently, self-responsibility for profits and losses, this model is known as the "insurance contract model." These models have significant effects, for example, the participation rate of social security substantially increased, reduced the cost of social security operations, improved efficiency, conducive to social security. Supervision of activities and promotion of Business insurance company development.
Chapter Four, the problems and future development suggestions of the entrusted management of social medical insurance in China. Although China has developed two modes of entrusted management of social medical insurance: fund management mode and insurance contract mode, the development of these two modes is still in the initial stage and there are many defects. The first is the "fund management model", the main problems are: lack of market competition, less market competition; small-scale social security funds, social security resources have not been optimized allocation; lack of regulatory mechanisms for the operation and management of social security funds. Implement "managed competition" while encouraging competition, carry out appropriate management, so that some high-quality small and medium-sized insurance companies can also participate in the management of social medical insurance. 2. Open up the social security business to commercial insurance companies management. 3. Expand the entrusted management pilot, increase the promotion of successful experience. 4. Speed up the social security entrusted management of special. If we don't set up the normative document of social medical insurance entrusted management, our country's reform in this respect may go to the state of anarchy. Its future development suggestions are as follows: 1. Encouraging commercial insurance companies to develop medical insurance products. From the international experience, the introduction of competition mechanism among the management subjects of social medical insurance funds has achieved remarkable results. In addition to relying on the powerful administrative power of the government, it is also necessary to enact relevant laws and strengthen the mutual supervision of commercial insurance companies. Media supervision is also an important aspect. 3. Clear government position and encourage commercial insurance companies to participate in management.
The main contributions of this paper are as follows: 1. This paper systematically summarizes the experience of social medical insurance commission management in the United States, Germany, the Netherlands and the United Kingdom, compares and analyzes the development models of these countries. 2. This paper elaborates the commission management models of social medical insurance in Xiamen, Xinxiang, Jiangyin and Zhanjiang in detail, and puts them into practice. Finally, the author summarizes the achievements of the entrusted management of social medical insurance in China, analyzes the existing problems and puts forward some suggestions for future development.
The inadequacies of this paper are as follows: 1, due to the limited time and ability, in the analysis of social medical insurance model at home and abroad, did not make a good summary and analysis. 2, due to the difficulty of data acquisition, a lot of research data are not collected, which affects the empirical of the article. 3, the author did not know the domestic and foreign social security commissions on the spot. The management of the Commission Office is lack of practical experience. The opinions and suggestions put forward in this paper are pale and weak, and still need to go through the test of time and practice.
【學(xué)位授予單位】：西南財經(jīng)大學(xué)
【學(xué)位級別】：碩士
【學(xué)位授予年份】：2013
【分類號】：F842.3

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