【摘要】：醫(yī)療保險是社會保障中重要的組成部分之一,它在減輕人民生活負(fù)擔(dān)、提高人民生活質(zhì)量和穩(wěn)定社會治安方面有著突出的作用,對滿足參保者醫(yī)療需求方面有著不可推卸的責(zé)任。然而現(xiàn)如今醫(yī)療保險出現(xiàn)了"看病貴,看病難"、醫(yī)療費用過快增長、參保者負(fù)擔(dān)加重、政府財政基金壓力大等問題,這些成為政府和人民極其關(guān)注的問題。在這個背景下醫(yī)療保險費用支付方式成為了眾矢之的,政府將緩解以上問題的希望放在了改革醫(yī)療保險費用支付方式上。這些年來我們一直在努力,從按服務(wù)項目付費的后付制到現(xiàn)如今正在實行的預(yù)付制,從過去單一的醫(yī)療保險費用支付方式到現(xiàn)如今的混合型的支付方式,不難得出中國的醫(yī)療保險費用支付方式正在向更加科學(xué)更加合理的道路上前行。筆者認(rèn)為在改革的道路上總結(jié)前人經(jīng)驗,吸取前人教訓(xùn)是很有必要的,因而選取了美國作為研究對象,比較了中國和美國的醫(yī)療保險費用支付方式,希望幫助到我國的醫(yī)療保險費用支付方式改革。美國是世界上醫(yī)療衛(wèi)生開支最大的國家,對醫(yī)療保險費用支付方式的改革起步較早,一直在不斷探索控制醫(yī)療保險費用增長的支付方式,這其中有成功也有失敗,總結(jié)起來就是寶貴的經(jīng)驗教訓(xùn)。文章以中國和美國的醫(yī)療保險費用支付方式現(xiàn)狀為切入點,應(yīng)用對比分析法、文獻(xiàn)研究法、國外借鑒法、經(jīng)驗總結(jié)法等方法,闡述了中國醫(yī)療保險費用支付方式的現(xiàn)狀,和總額預(yù)付制會推諉重癥患者、總額預(yù)付制將降低醫(yī)療服務(wù)質(zhì)量、總額預(yù)付制標(biāo)準(zhǔn)測算出現(xiàn)偏差、按病種付費會轉(zhuǎn)移醫(yī)療費用的問題。這些問題的成因是支付方式的監(jiān)管機制不健全和很難區(qū)分合理的和不合理的費用。與此同時還介紹了美國醫(yī)療保險費用支付方式的現(xiàn)狀、效果和改革經(jīng)驗,并將兩國的醫(yī)療保險費用支付方式的內(nèi)容、改革效果、改革進(jìn)度進(jìn)行了比較分析,得出美國醫(yī)療保險費用支付方式的啟示,并對中國的醫(yī)療保險費用支付方式給出對策建議,建議分為兩方面,一方面是關(guān)于支付方式微觀影響因素的建議,一方面是關(guān)于醫(yī)療保險費用支付方式宏觀影響因素的建議。關(guān)于支付方式微觀影響因素的建議有:支付方式的制定要因地制宜、效仿美國管理式醫(yī)療支付方式、推進(jìn)全國性的復(fù)合型支付方式、加快按病種付費向DRGs的過渡。關(guān)于支付方式宏觀因素的建議有:完善各項管理措施及獎懲機制、積極引入費用支付談判機制、科學(xué)制定總額預(yù)付制支付標(biāo)準(zhǔn)。
[Abstract]:Medical insurance is one of the important components of social security. It plays a prominent role in reducing the burden of people's life, improving the quality of life of the people and stabilizing social order. There is an unshirkable responsibility for meeting the medical needs of the insured. Nowadays, however, medical insurance has appeared such problems as "expensive to see a doctor, difficult to see a doctor", excessive increase in medical expenses, increased burden on insured persons, and heavy pressure on government financial funds. These problems have become extremely concerned by the government and the people. In this context, medical insurance payment has become a popular criticism, the government will alleviate the above problems on the reform of health insurance payment. Over the years, we've been working on everything from the post-pay-per-service system to the prepaid system that is now in place, from the past single way of paying for health insurance to the current hybrid mode of payment. It is easy to conclude that China's health insurance payment is moving towards a more scientific and rational way. The author thinks that it is necessary to sum up the previous experience and draw lessons from the former on the road of reform. Therefore, the author chooses the United States as the research object, and compares the payment methods of medical insurance costs between China and the United States. We hope to help the reform of medical insurance payment in our country. The United States, which has the largest medical and health expenditure in the world, has been exploring ways to control the growth of medical insurance costs, including success and failure. To sum up is a valuable lesson. Based on the current situation of medical insurance payment in China and the United States, this paper discusses the current situation of medical insurance payment in China by means of comparative analysis, literature research, foreign reference, experience summary and so on. The total prepaid system will degrade the quality of medical service, the standard calculation of total prepaid system will deviate, and the payment by disease will transfer the medical expenses. The causes of these problems are that the payment mechanism is not perfect and it is difficult to distinguish between reasonable and unreasonable costs. At the same time, it also introduces the current situation, effect and reform experience of the medical insurance payment method in the United States, and makes a comparative analysis of the content, the reform effect and the reform progress of the two countries' medical insurance expense payment method. This paper draws the enlightenment of the payment method of American medical insurance expenses, and gives some countermeasures and suggestions on the payment of medical insurance expenses in China. The suggestions can be divided into two aspects: one is the suggestion on the microcosmic influencing factors of the payment method, On the one hand is about the medical insurance expense payment way macroscopic influence factor's suggestion. Some suggestions on the micro influencing factors of payment methods are as follows: the formulation of payment methods should be adapted to local conditions, follow the management medical payment mode of the United States, promote the national compound payment mode, and speed up the transition from payment by disease to DRGs. Some suggestions on macro factors of payment are as follows: perfecting various management measures and mechanism of reward and punishment, actively introducing negotiation mechanism of payment of expenses, and scientifically formulating the standard of payment in advance system of total amount.
【學(xué)位授予單位】：哈爾濱商業(yè)大學(xué)
【學(xué)位級別】：碩士
【學(xué)位授予年份】：2017
【分類號】：F842.684;F847.12

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