拉薩市醫(yī)療保險付費(fèi)方式研究
發(fā)布時間：2018-10-15 17:25
【摘要】：目前，我國的醫(yī)療衛(wèi)生和醫(yī)療保障領(lǐng)域存在許多問題，“看病貴、看病難”的問題是這諸多問題中的一個突出問題，嚴(yán)重影響到人民群眾醫(yī)療保障需求的滿足。為解決這一問題，在醫(yī)療衛(wèi)生領(lǐng)域進(jìn)行了多項(xiàng)改革，而對基本醫(yī)療保險付費(fèi)方式的改革是諸多改革中重點(diǎn)。通過付費(fèi)方式和模式的改革，可以更好的管控醫(yī)療服務(wù)機(jī)構(gòu)的各種行為（重點(diǎn)是醫(yī)療服務(wù)行為），進(jìn)而達(dá)到控制醫(yī)療服務(wù)成本，抑制醫(yī)療費(fèi)用過分支出，最終達(dá)到緩解醫(yī)保經(jīng)費(fèi)支付的壓力，化解支付風(fēng)險的目的。通過各項(xiàng)改革，將人民群眾在看病就醫(yī)時的經(jīng)濟(jì)損失降到最低。如今世界上存在六種主要的醫(yī)療保險付費(fèi)方式，即按服務(wù)項(xiàng)目付費(fèi)、按病種付費(fèi)、總額預(yù)付、按人頭付費(fèi)、按單元付費(fèi)和定額結(jié)算。對每種付費(fèi)方式進(jìn)行比較分析，都能發(fā)現(xiàn)這一付費(fèi)方式存在一定的優(yōu)勢和一定的使用范圍，同時，每一種付費(fèi)方式也存在不足。在實(shí)踐中，基本醫(yī)療保險管理部門會根據(jù)實(shí)際情況需要，組合使用不同付費(fèi)方式，形成復(fù)合式的醫(yī)療保險付費(fèi)模式。目前，在中國，覆蓋全國所有公民的基本醫(yī)療保險制度已基本建立，主要包括三項(xiàng)制度：即針對廣大農(nóng)村居民的新農(nóng)合制度、針對城鎮(zhèn)沒有就業(yè)人口的城鎮(zhèn)居民醫(yī)保制度和針對城鎮(zhèn)就業(yè)人口的城鎮(zhèn)職 工醫(yī)保制度，三項(xiàng)制度基本上已經(jīng)能夠覆蓋我國所有的人群。不過，在統(tǒng)一的制度體系下，具體的運(yùn)行方式會有所不同，體現(xiàn)在醫(yī)療保險付費(fèi)方式上，就是不同地區(qū)所具體使用的付費(fèi)方式并不一模一樣。近年來，多個地方進(jìn)行了醫(yī)療保障制度和醫(yī)療衛(wèi)生體制的改革，在這些改革中，付費(fèi)方式的改革一直都是重要內(nèi)容之一。在一定程度上，各個地方現(xiàn)行的基本醫(yī)療保險付費(fèi)方式都有一定的效果，對于費(fèi)用上漲的控制、患者負(fù)擔(dān)的減輕都能起到一定作用，但也有控制醫(yī)療費(fèi)用與滿足醫(yī)療需求之間存在矛盾、醫(yī)療保險經(jīng)辦機(jī)構(gòu)管理成本偏高、落實(shí)定點(diǎn)醫(yī)療服務(wù)機(jī)構(gòu)內(nèi)部管理不足等問題仍然需要進(jìn)一步解決。 從總體上看，拉薩市基本醫(yī)療保險制度中，依然沿用按服務(wù)項(xiàng)目付費(fèi)這種比較傳統(tǒng)的付費(fèi)方式，是一種比較簡單而且單一的付費(fèi)方式。這種付費(fèi)方式的使用在短期內(nèi)沒有影響到整個基本醫(yī)療保險體制的運(yùn)行，但從長遠(yuǎn)來看，還需要調(diào)整和完善。通過綜合分析國內(nèi)外現(xiàn)行醫(yī)療保險付費(fèi)方式、比較分析我國和拉薩市現(xiàn)行付費(fèi)方式和模式，本文提出在拉薩市，有必要對現(xiàn)行的付費(fèi)方式進(jìn)行改革和完善，在改革中，首先要吸取其他地方醫(yī)療保險付費(fèi)方式改革的成功經(jīng)驗(yàn)，其次要加快城鄉(xiāng)基本醫(yī)療保險制度的統(tǒng)一和整合，三是要積極探索實(shí)行有效機(jī)制，，實(shí)現(xiàn)定點(diǎn)醫(yī)療服務(wù)機(jī)構(gòu)的分級分類管理，最后要探索有效手段，建立健全專家談判協(xié)商的機(jī)制。希望在西藏自治區(qū)的基本醫(yī)療保障制度的改革中，這些建議可以發(fā)揮一些積極的影響。
[Abstract]:At present, there are many problems in the field of health care and medical security in our country. The problem of "seeing a doctor is expensive but difficult to see a doctor" is one of the outstanding problems, which seriously affects the satisfaction of the people's medical security needs. In order to solve this problem, many reforms have been carried out in the field of medical and health care, and the reform of the basic medical insurance payment method is the focus of many reforms. Through the reform of payment mode and mode, we can better control all kinds of behavior of medical service organization (focus on medical service behavior), and then control the cost of medical service and restrain the excessive expenditure of medical cost. Finally, the purpose of relieving the pressure of medical insurance payment and reducing the risk of payment is achieved. Through various reforms, the economic loss of the masses when seeking medical treatment was reduced to the minimum. Nowadays, there are six main ways to pay for medical insurance in the world, that is, by service item, by disease, by total advance, by head, by unit and by quota. Through the comparative analysis of each payment method, we can find that there are certain advantages and certain scope of use of this payment method, and at the same time, each payment method also has some shortcomings. In practice, the basic medical insurance management department will combine different payment methods according to the actual situation to form a compound medical insurance payment mode. At present, in China, a basic medical insurance system covering all citizens of the country has basically been established, which mainly includes three systems: a new rural cooperative system for the majority of rural residents. For the medical insurance system of urban residents without employment in cities and towns and the occupational insurance system of urban workers in cities and towns, the three systems can basically cover all the people in our country. However, under the unified system, the specific mode of operation will be different, reflected in the medical insurance payment method, that is, different regions of the specific use of payment methods are not the same. In recent years, many places have carried on the medical security system and the health care system reform, in these reforms, the payment way reform has been one of the important contents. To a certain extent, the existing basic medical insurance payment methods in various localities have certain effects, which can play a certain role in controlling the increase in costs and reducing the burden on patients. However, there are also contradictions between controlling medical expenses and meeting medical needs. The management cost of medical insurance agencies is on the high side, and the internal management of designated medical service institutions needs to be further solved. Generally speaking, in the basic medical insurance system of Lhasa, it is a relatively simple and single way to pay by service items, which is a more traditional way of payment. The use of this payment method does not affect the operation of the whole basic medical insurance system in the short term, but in the long run, it still needs to be adjusted and improved. Based on the comprehensive analysis of the current medical insurance payment methods at home and abroad, and the comparative analysis of the current payment methods and models between China and Lhasa, this paper points out that it is necessary to reform and perfect the current payment methods in Lhasa, and in the course of the reform, First of all, we should absorb the successful experience of other localities in the reform of medical insurance payment methods; secondly, we should speed up the unification and integration of the basic medical insurance system in urban and rural areas; and third, we should actively explore and implement effective mechanisms. Finally, it is necessary to explore effective means to establish and perfect the mechanism of expert negotiation and consultation. It is hoped that these suggestions will play a positive role in the reform of the basic medical security system in Tibet Autonomous region.
【學(xué)位授予單位】：西藏大學(xué)
【學(xué)位級別】：碩士
【學(xué)位授予年份】：2014
【分類號】：F842.684;R197.1
[Abstract]:At present, there are many problems in the field of health care and medical security in our country. The problem of "seeing a doctor is expensive but difficult to see a doctor" is one of the outstanding problems, which seriously affects the satisfaction of the people's medical security needs. In order to solve this problem, many reforms have been carried out in the field of medical and health care, and the reform of the basic medical insurance payment method is the focus of many reforms. Through the reform of payment mode and mode, we can better control all kinds of behavior of medical service organization (focus on medical service behavior), and then control the cost of medical service and restrain the excessive expenditure of medical cost. Finally, the purpose of relieving the pressure of medical insurance payment and reducing the risk of payment is achieved. Through various reforms, the economic loss of the masses when seeking medical treatment was reduced to the minimum. Nowadays, there are six main ways to pay for medical insurance in the world, that is, by service item, by disease, by total advance, by head, by unit and by quota. Through the comparative analysis of each payment method, we can find that there are certain advantages and certain scope of use of this payment method, and at the same time, each payment method also has some shortcomings. In practice, the basic medical insurance management department will combine different payment methods according to the actual situation to form a compound medical insurance payment mode. At present, in China, a basic medical insurance system covering all citizens of the country has basically been established, which mainly includes three systems: a new rural cooperative system for the majority of rural residents. For the medical insurance system of urban residents without employment in cities and towns and the occupational insurance system of urban workers in cities and towns, the three systems can basically cover all the people in our country. However, under the unified system, the specific mode of operation will be different, reflected in the medical insurance payment method, that is, different regions of the specific use of payment methods are not the same. In recent years, many places have carried on the medical security system and the health care system reform, in these reforms, the payment way reform has been one of the important contents. To a certain extent, the existing basic medical insurance payment methods in various localities have certain effects, which can play a certain role in controlling the increase in costs and reducing the burden on patients. However, there are also contradictions between controlling medical expenses and meeting medical needs. The management cost of medical insurance agencies is on the high side, and the internal management of designated medical service institutions needs to be further solved. Generally speaking, in the basic medical insurance system of Lhasa, it is a relatively simple and single way to pay by service items, which is a more traditional way of payment. The use of this payment method does not affect the operation of the whole basic medical insurance system in the short term, but in the long run, it still needs to be adjusted and improved. Based on the comprehensive analysis of the current medical insurance payment methods at home and abroad, and the comparative analysis of the current payment methods and models between China and Lhasa, this paper points out that it is necessary to reform and perfect the current payment methods in Lhasa, and in the course of the reform, First of all, we should absorb the successful experience of other localities in the reform of medical insurance payment methods; secondly, we should speed up the unification and integration of the basic medical insurance system in urban and rural areas; and third, we should actively explore and implement effective mechanisms. Finally, it is necessary to explore effective means to establish and perfect the mechanism of expert negotiation and consultation. It is hoped that these suggestions will play a positive role in the reform of the basic medical security system in Tibet Autonomous region.
【學(xué)位授予單位】：西藏大學(xué)
【學(xué)位級別】：碩士
【學(xué)位授予年份】：2014
【分類號】：F842.684;R197.1
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