【摘要】：隨著社會(huì)生產(chǎn)力的進(jìn)一步發(fā)展和人民生活水平的不斷提高,社會(huì)保險(xiǎn)在國(guó)民生活中發(fā)揮著愈來(lái)愈重要的作用。大病保險(xiǎn)承擔(dān)著極其重要的社會(huì)保障職能,通過(guò)對(duì)重大疾病的報(bào)銷(xiāo),重大疾病患者的經(jīng)濟(jì)負(fù)擔(dān)得到了大大的減輕。近些年,城鄉(xiāng)居民大病保險(xiǎn)正在以市場(chǎng)機(jī)制逐步進(jìn)入到社會(huì)保障制度,并取得到了相當(dāng)滿意的效果,同時(shí)在基本政策方面有了很大的進(jìn)步,具有代表性的是:補(bǔ)償比例方面、融資籌集方面、費(fèi)用處理方面、結(jié)算管理方面等。但是在實(shí)踐過(guò)程中,大病保險(xiǎn)依然面臨種種考驗(yàn),商業(yè)保險(xiǎn)公司承辦的大病保險(xiǎn)在政策法規(guī)、籌資水平、政商系統(tǒng)對(duì)接、合作模式、隱性價(jià)格競(jìng)爭(zhēng)等方面存在諸多問(wèn)題。此外,大病保險(xiǎn)在公共財(cái)政支出與商業(yè)保險(xiǎn)公司之間的有效銜接仍然存有一些問(wèn)題,這一點(diǎn)表現(xiàn)在公共財(cái)政的支付與商業(yè)保險(xiǎn)公司的對(duì)接環(huán)節(jié)尤為明顯。本文希望通過(guò)從解決這些問(wèn)題入手,將商業(yè)保險(xiǎn)公司承辦的大病保險(xiǎn)業(yè)務(wù)的核心問(wèn)題得以理順。首先,本文以經(jīng)營(yíng)者地位的商業(yè)保險(xiǎn)公司為視角,采取文獻(xiàn)分析法、比較分析法等研究方法,通過(guò)了解典型的幾個(gè)模式,更為清晰地分析商業(yè)保險(xiǎn)公司在承辦大病保險(xiǎn)業(yè)務(wù)活動(dòng)時(shí)的真實(shí)狀況。并借此對(duì)目前我國(guó)商業(yè)保險(xiǎn)公司在承辦大病保險(xiǎn)過(guò)程中存在的問(wèn)題從三個(gè)方面進(jìn)行分析:政策法規(guī)不健全,如相關(guān)法律法規(guī)不健全、政府監(jiān)管錯(cuò)位越位現(xiàn)象時(shí)有發(fā)生、醫(yī)療保險(xiǎn)政策缺乏整體性設(shè)計(jì);大病保險(xiǎn)基金浪費(fèi)現(xiàn)象缺乏有效對(duì)策,如醫(yī)院“過(guò)度醫(yī)療”,監(jiān)督管理方式單一、醫(yī)療信息缺少共享,“智能審核”應(yīng)用水平有待增強(qiáng)、醫(yī)療保險(xiǎn)支出績(jī)效評(píng)估不足,醫(yī)療保險(xiǎn)效果定量分析不足;大病保險(xiǎn)特點(diǎn)、機(jī)制、標(biāo)準(zhǔn)探究不足,導(dǎo)致大病醫(yī)療保障水平較低。最后,針對(duì)出現(xiàn)的問(wèn)題提出一些對(duì)策和建議,不僅從政府的政策層面,配合多元利益需求,合理、科學(xué)建構(gòu)整體法律框架;而且創(chuàng)新思路,加強(qiáng)對(duì)各參與主體的監(jiān)管與考核,加強(qiáng)監(jiān)管醫(yī)院“過(guò)度醫(yī)療”,推廣“智能審核”信息化手段運(yùn)用,且引入第三方機(jī)構(gòu),對(duì)醫(yī)療保險(xiǎn)效果進(jìn)行評(píng)估;同時(shí),隨著大病保險(xiǎn)的推廣與深入研究,要綜合施策,提高大病保險(xiǎn)保障水平,加強(qiáng)對(duì)大病保險(xiǎn)特點(diǎn)的分析研究,建立商業(yè)保險(xiǎn)與社會(huì)保險(xiǎn)聯(lián)動(dòng)工作機(jī)制,制定統(tǒng)一的大病保險(xiǎn)保障標(biāo)準(zhǔn)。
[Abstract]:With the further development of social productivity and the continuous improvement of people's living standard, social insurance plays an increasingly important role in national life. The serious illness insurance plays an extremely important role in social security, and the financial burden of the patients with the major diseases is greatly reduced through the reimbursement of the major diseases. In recent years, urban and rural residents' serious illness insurance is gradually entering the social security system through the market mechanism, and has achieved quite satisfactory results. At the same time, great progress has been made in the basic policies. Financing aspects, cost handling, settlement management, etc. However, in the process of practice, the serious illness insurance still faces various tests. There are many problems in the policies and regulations, the level of financing, the docking of the government and business system, the cooperation mode, the hidden price competition and so on. In addition, there are still some problems in the effective connection between public expenditure and commercial insurance companies, which is especially obvious in the connection between public finance payment and commercial insurance companies. Through solving these problems, this paper hopes to straighten out the core problems of the serious illness insurance business undertaken by commercial insurance companies. First of all, from the angle of view of commercial insurance company with operator status, this paper adopts literature analysis, comparative analysis and other research methods to understand several typical models. A clearer analysis of the real situation of commercial insurance companies in undertaking major illness insurance business activities. In this way, the problems existing in the process of undertaking the insurance of serious illness in China's commercial insurance companies are analyzed from three aspects: the imperfect policies and regulations, such as the imperfect laws and regulations, the phenomenon of government supervision misplacing and offside, which occur from time to time. The medical insurance policy lacks the overall design, the serious illness insurance fund waste phenomenon lacks the effective countermeasure, such as the hospital "excessive medical treatment", the supervision and management way is single, the medical information is not shared, the application level of "intelligent audit" needs to be strengthened. The medical insurance expenditure performance evaluation is insufficient, the medical insurance effect quantitative analysis is insufficient, the serious illness insurance characteristic, the mechanism, the standard exploration insufficiency, causes the serious illness medical treatment safeguard level to be low. Finally, some countermeasures and suggestions are put forward to solve the problems, not only from the government policy level, to meet the needs of multiple interests, but also to construct the overall legal framework scientifically, and to create new ideas to strengthen the supervision and assessment of the participants. Strengthen supervision of hospital "excessive medical treatment", popularize the use of "intelligent audit" information means, and introduce third party organizations to evaluate the effect of medical insurance; at the same time, with the promotion and in-depth study of the insurance for serious illness, we should comprehensively implement countermeasures. To improve the level of insurance for serious illness, to strengthen the analysis and research on the characteristics of the insurance of serious illness, to establish the working mechanism of the linkage between commercial insurance and social insurance, and to formulate a unified standard of insurance for serious illness.
【學(xué)位授予單位】：山西大學(xué)
【學(xué)位級(jí)別】：碩士
【學(xué)位授予年份】：2017
【分類(lèi)號(hào)】：F842.6

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