本文選題：職工醫(yī)療保險　切入點：結(jié)算方式　出處：《西北農(nóng)林科技大學(xué)》2017年碩士論文　論文類型：學(xué)位論文

【摘要】：隨著我國醫(yī)療的改革不斷深入,醫(yī)療保險經(jīng)費出現(xiàn)的不合理支出問題,究其原因,還是因為醫(yī)療保險制度跟不上社會經(jīng)濟的發(fā)展。這種滯后性帶來的問題將會對參保人員的保障權(quán)益產(chǎn)生根本性影響,也對醫(yī)療保險制度的穩(wěn)定性、可持續(xù)性提出了挑戰(zhàn)。因此研究人員對于醫(yī)療保險制度的設(shè)計關(guān)注度正在不斷提升,希望能找到醫(yī)療保險基金的控制機制改進之路,使醫(yī)療基金的使用效率得到有效的提升。在醫(yī)療保險制度的設(shè)計中醫(yī)療保險基金的問題是重中之重,而結(jié)算方式又是醫(yī)療保險基金能夠良好運行的關(guān)鍵。結(jié)算方式作為一種制度措施,保障著參保人員的基本醫(yī)保待遇、控制著醫(yī)療服務(wù)方的過度醫(yī)療行為,有效發(fā)揮醫(yī)�；鸬妮敵鲎饔谩Ｒ虼藢τ卺t(yī)�；鸾Y(jié)算方式的現(xiàn)狀與趨勢的研究,不僅能使我們最大限度提高醫(yī)�；鸬氖褂眯�,更好地發(fā)揮醫(yī)�；鸾y(tǒng)籌共濟的作用,最終達到醫(yī)療服務(wù)需求方和供給方雙方共贏的目的。而且能在政策方面幫助加強醫(yī)�；鸬墓芾�,不斷推進可持續(xù)發(fā)展的醫(yī)療保險制度,為新一輪醫(yī)療衛(wèi)生體制改革提供理論技術(shù)支持。本文通過對已有的研究成果、相關(guān)理論概括以及國內(nèi)外相關(guān)醫(yī)療保險結(jié)算方式進行對比研究,綜合分析得出我國醫(yī)療保險制度改革中關(guān)于結(jié)算方式的借鑒性意見和建議:第一建立健全具有中國社會主義特色的醫(yī)療保險法律體系;第二綜合運用各種醫(yī)療費用的結(jié)算方式;第三明確參保者的個人責(zé)任;第四重復(fù)發(fā)揮商業(yè)醫(yī)療保險的補充作用;第五實現(xiàn)政府與市場機制的有效結(jié)合。同時,通過對蘇州市吳江區(qū)醫(yī)療保險制度的發(fā)展改革道路進行梳理,針對其中結(jié)算方式的變革,提出了完善吳江區(qū)職工醫(yī)療保險結(jié)算方式的對策建議:一是進一步實施醫(yī)療保險的混合型結(jié)算方式、彈性結(jié)算方式等;二是健全法律法規(guī)體系,加強保險經(jīng)辦機構(gòu)內(nèi)控機制建設(shè);三是建立互聯(lián)共享的信息網(wǎng)絡(luò)平臺,深化誠信體系建設(shè);四是發(fā)揮社區(qū)衛(wèi)生服務(wù)在醫(yī)療服務(wù)中的基礎(chǔ)性作用。本文的研究立足于吳江區(qū)職工醫(yī)療保險的實際情況,通過筆者在吳江醫(yī)療保險經(jīng)辦機構(gòu)多年的工作經(jīng)驗,并作為醫(yī)療機構(gòu)執(zhí)法監(jiān)督者的多次實地考察結(jié)果,分析吳江區(qū)職工醫(yī)療保險結(jié)算方式的現(xiàn)狀及其存在的問題提出完善吳江區(qū)醫(yī)療保險的對策。文章全面系統(tǒng)的研究了吳江區(qū)職工醫(yī)療保險的結(jié)算方式,希望能夠進一步完善吳江區(qū)職工醫(yī)療保險結(jié)算方式,有助于指導(dǎo)吳江區(qū)社保經(jīng)辦機構(gòu)今后的監(jiān)管工作,同時為其他孜孜不倦研究職工醫(yī)療保險結(jié)算方式的學(xué)者提供一點參考資料。各國都在對醫(yī)療制度進行不斷的改革與完善,為了控制持續(xù)快速增長的醫(yī)療費用,完善醫(yī)療保險控制機制,因地制宜的選擇結(jié)算方式必不可少,同時這也將成為醫(yī)療保險改革的巨大助力。本論文的意義則是在于立足吳江現(xiàn)狀,為完善吳江區(qū)職工醫(yī)療保險體系提供可行性建議,更對推進醫(yī)療保險制度改革實踐具有一定的指導(dǎo)意義。
[Abstract]:With the deepening reform of China's health, unreasonable expenditure of medical insurance funds appears, the reason is because of the development of medical insurance system and social economy. This lag problems will safeguard the rights and interests of insured persons have a fundamental impact on the stability of the medical insurance system, also put forward. The challenge of sustainability. Therefore researchers concern for the design of the medical insurance system is rising, hopes to improve the control mechanism of the medical insurance fund to find the road, make efficient use of medical funds improve the medical insurance system. In the design of medical insurance fund problem is the priority among priorities, and settlement what is the key to the medical insurance fund operation. As a system of measures of settlement, protection of basic health care treatment of the insured, control of medical service Excessive medical care service, effectively play the role of the health insurance fund. Therefore the output status and trend for the settlement of the medical insurance fund research, so we can not only maximize the efficiency of the use of insurance funds, better play the role of co-ordinate Masonic medical insurance fund, and ultimately achieve the demand for medical services and supply the win-win purpose and can help strengthen the management of medical insurance fund in terms of policy, continue to promote the sustainable development of medical insurance system, provide theoretical and technical support for a new round of reform of the medical and health system. Based on the existing research results, comparative study related theory summary and related domestic and foreign medical insurance settlement, suggestions and advice on the settlement of the medical insurance system reform in our country comprehensive analysis: first establish a socialist Chinese The legal system of medical insurance; medical expenses settlement second comprehensive; third clear insured personal responsibility; fourth repeat to play a complementary role of the commercial medical insurance; realize the effective combination of government and market mechanism fifth. At the same time, through sorting out the road of development and reform of medical insurance system in Wujiang District of Suzhou City, according to the settlement change the way, put forward suggestions to improve the Wujiang district medical insurance settlement: a mixed settlement further implementation of medical insurance, flexible such as clearing the way; two is to improve the legal system, strengthen the construction of the internal control mechanism of insurance mechanism; three is to establish information sharing platform for the Internet network, deepening the construction of credit system; four is the basic function of community health service use in medical services. Based on the research of Wujiang district staff medical insurance The actual situation in Wujiang, the medical insurance agency for many years of work experience, and as a medical institution supervisors on-the-spot investigation results, analysis of the current situation of Wujiang medical insurance settlement and the existing problems and puts forward suggestions of perfecting Wujiang district medical insurance. The comprehensive and systematic study of the Wujiang district staff medical insurance clearing the way, hope to be able to further improve the Wujiang district staff medical insurance settlement, will help guide Wujiang district social security agencies in the supervision work, and provide references for other studies diligently medical insurance settlement scholars. Most of the countries in the medical system of continuous reform and improvement, in order to control the rapid the growth of medical costs, improve the control mechanism of medical insurance, select the settlement will not be less, At the same time, this will also become a great help for the reform of medical insurance. The significance of this paper is based on the current situation of Wujiang, which provides a feasible proposal for improving the medical insurance system of employees in Wujiang District, and has a certain guiding significance for promoting the practice of medical insurance system reform.

【學(xué)位授予單位】：西北農(nóng)林科技大學(xué)
【學(xué)位級別】：碩士
【學(xué)位授予年份】：2017
【分類號】：R197.1;F842.684

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