發(fā)布時間：2018-03-19 08:51

  本文選題：醫(yī)療保障權(quán)　切入點(diǎn)：基本醫(yī)療保險　出處：《西南政法大學(xué)》2015年碩士論文　論文類型：學(xué)位論文

【摘要】：隨著我國經(jīng)濟(jì)發(fā)展水平和老百姓生活質(zhì)量的不斷提高完善,如何過上身心健康、體面尊嚴(yán)的生活已經(jīng)成為政府和老百姓關(guān)注的頭等大事。在實(shí)踐層面,我國各級衛(wèi)生部門、民政部門等為此做出了一系列努力。從1952年以公費(fèi)醫(yī)療保障制度和勞保醫(yī)療制度為主體的城鎮(zhèn)醫(yī)療保障制度建立之時起,到之后我國城鎮(zhèn)職工醫(yī)療保險、新型農(nóng)村合作醫(yī)療保險(以下簡稱“新農(nóng)合”)和城鎮(zhèn)居民基本醫(yī)療保險相繼建立,我國目前實(shí)現(xiàn)了基本醫(yī)療保險全覆蓋。在法制建設(shè)層面,我國有關(guān)醫(yī)療保險的法律制度不斷完善,公民的“醫(yī)療保障權(quán)”和“人權(quán)”相繼寫入了《憲法》,《工傷保險條例》、《社會保險法》等陸續(xù)出臺。目前,以《憲法》、《社會保險法》等法律為基礎(chǔ),我國已經(jīng)初步建立起以城鎮(zhèn)職工保險、城鄉(xiāng)居民保險和“新農(nóng)合”為主體的基本醫(yī)療保險制度體系。問題是,隨著社會經(jīng)濟(jì)的發(fā)展進(jìn)步,我國人口流動性日漸增強(qiáng),基本醫(yī)療保險參保人員異地就醫(yī)的現(xiàn)象日趨普遍,但我國并沒有建立起基本醫(yī)療保險的統(tǒng)一制度。1998年,國務(wù)院頒布《關(guān)于建立城鎮(zhèn)職工基本醫(yī)療保險制度的決定》(國發(fā)[1998]44號),確立了城鎮(zhèn)職工基本醫(yī)療保險實(shí)行市級統(tǒng)籌的制度。在這一政策的引導(dǎo)下,此后的城鎮(zhèn)居民醫(yī)療保險與“新農(nóng)合”均沿用了市級統(tǒng)籌的制度設(shè)計(jì)。由此產(chǎn)生的一個不可忽視的法律問題是:由基本醫(yī)療保險統(tǒng)籌層次低造成的醫(yī)保政策“碎片化”,使得參保人員在異地就醫(yī)時無法享受到相對公平和高效的就醫(yī)待遇。異地就醫(yī)結(jié)算過程中的公平與效率問題凸顯。除引言和結(jié)語外,論文共分為五個部分。第一部分是“基本醫(yī)療保險異地就醫(yī)結(jié)算一般分析”。結(jié)合基本醫(yī)療保險制度,分析在此制度之下異地就醫(yī)的成因和異地就醫(yī)結(jié)算的現(xiàn)象。異地就醫(yī)是由各地醫(yī)療衛(wèi)生資源分布不平衡、參保人員就醫(yī)需求與醫(yī)療資源分布不均之間的矛盾以及人口流動等諸多原因共同造成的。異地就醫(yī)結(jié)算是基本醫(yī)療保險參保人員在參保地區(qū)之外就醫(yī)后患者與診療醫(yī)院、診療醫(yī)院與社保經(jīng)辦機(jī)構(gòu)之間進(jìn)行的結(jié)算。目前,我國患者異地就醫(yī)的規(guī)模增長迅速,相應(yīng)地,異地就醫(yī)保險結(jié)算的規(guī)模隨之?dāng)U大,相關(guān)主體對異地就醫(yī)保險結(jié)算的要求更加復(fù)雜和多樣化起來。第二部分是“我國基本醫(yī)療保險異地就醫(yī)結(jié)算的主要法律問題”。我國基本醫(yī)療保險制度具有“碎片化”的特點(diǎn),即在不同的統(tǒng)籌地區(qū),基本醫(yī)療保險的保障水平、保障實(shí)施的條件和程序等存在諸多差異,而異地就醫(yī)結(jié)算過程中的法律問題值得深入分析。第一,參保人員異地就醫(yī)面臨突出的不公平問題。一方面,參保人員異地就醫(yī)報(bào)銷待遇差異過大,呈現(xiàn)出不同統(tǒng)籌地區(qū)參保人員在使用同等水平醫(yī)療資源情況下報(bào)銷水平不同的特點(diǎn)。另一方面,由于異地結(jié)算真實(shí)性的監(jiān)管難度較大,醫(yī)保監(jiān)管部門實(shí)行一套較為繁瑣但對保險欺詐的監(jiān)管效果欠佳的報(bào)銷程序,導(dǎo)致不應(yīng)該被報(bào)銷的費(fèi)用得到報(bào)銷,參保人員應(yīng)當(dāng)合理報(bào)銷的費(fèi)用難以報(bào)銷,這對守法參保人員有顯著的不公平性。第二,異地就醫(yī)的實(shí)時結(jié)算機(jī)制尚未完全建立,大多數(shù)統(tǒng)籌地區(qū)的異地結(jié)算程序繁瑣,因?yàn)獒t(yī)療保險結(jié)算體制不合理,參保人員在異地就醫(yī)過程中實(shí)際上承受了許多不必要的負(fù)擔(dān)。第三部分是“基本醫(yī)療保險異地就醫(yī)結(jié)算法律問題的成因”�；踞t(yī)療保險異地就醫(yī)結(jié)算中法律問題的成因可以歸結(jié)為兩個方面:第一,基本醫(yī)療保險的統(tǒng)籌層次較低。一方面,我國最早建立的城鎮(zhèn)職工基本醫(yī)療保險統(tǒng)籌層次低,其后的城鄉(xiāng)居民保險與“新農(nóng)合”也延續(xù)了這一制度設(shè)計(jì),基本醫(yī)療保險的統(tǒng)籌層次設(shè)計(jì)具有歷史特點(diǎn),在歷次改革中還未取得突破性進(jìn)展;另一方面,我國地區(qū)之間的經(jīng)濟(jì)發(fā)展水平差異較大,但我國在分稅制財(cái)政管理體制基礎(chǔ)上的財(cái)政轉(zhuǎn)移支付制度未能有效均衡醫(yī)療資源配置,我國基本醫(yī)療保險政策“碎片化”的特點(diǎn)仍然十分明顯。第二,基本醫(yī)療保險異地就醫(yī)結(jié)算的管理與監(jiān)督制度不完善。主要表現(xiàn)為:實(shí)時結(jié)算機(jī)制欠缺,異地就醫(yī)結(jié)算保險欺詐的監(jiān)管主體混亂,異地就醫(yī)結(jié)算保險欺詐司法監(jiān)督打擊力度不夠。第四部分是“歐盟跨國就醫(yī)結(jié)算制度之考察”�？疾鞖W盟跨國就醫(yī)管理的解決方案,可以發(fā)現(xiàn),歐盟跨國就醫(yī)管理建立在協(xié)調(diào)性醫(yī)療保險政策之上,其協(xié)調(diào)性政策對于歐盟成員國公民跨國就醫(yī)的公平與高效均有所保障。一方面,協(xié)調(diào)性醫(yī)療保險政策以歐盟成員國公民應(yīng)該被公平平等地對待為原則;另一方面,標(biāo)準(zhǔn)化的管理、統(tǒng)一的跨國就醫(yī)申請表格、真正意義上的“一卡通”使得其公民的跨國就醫(yī)結(jié)算極為高效。第五部分是“破解我國基本醫(yī)療保險異地就醫(yī)結(jié)算法律問題的路徑”。筆者認(rèn)為,通過醫(yī)療資源的均等化安排、提高基本醫(yī)療保險統(tǒng)籌層次、完善基本醫(yī)療保險異地就醫(yī)結(jié)算管理與監(jiān)督制度,有助于解決我國基本醫(yī)療保險異地就醫(yī)結(jié)算過程中出現(xiàn)的法律問題。第一,通過醫(yī)療資源的均等化安排,尤其是對各地醫(yī)院的診療設(shè)施、醫(yī)護(hù)人員等醫(yī)療資源的均衡配置,可以從根本上引導(dǎo)參保人員合理就醫(yī),減少異地就醫(yī)結(jié)算的規(guī)模和資源消耗。第二,實(shí)行省級統(tǒng)籌,建立區(qū)域性異地就醫(yī)結(jié)算協(xié)調(diào)機(jī)制。通過財(cái)政轉(zhuǎn)移支付的手段,統(tǒng)一省內(nèi)基本醫(yī)療保險政策。通過簽訂異地就醫(yī)結(jié)算協(xié)議的方式,實(shí)現(xiàn)經(jīng)濟(jì)發(fā)展水平趨同區(qū)域基本醫(yī)療保險政策的互認(rèn)互惠。第三,完善基本醫(yī)療保險異地就醫(yī)結(jié)算管理與監(jiān)督制度,包括建立實(shí)時結(jié)算平臺、厘清監(jiān)管主體職責(zé)、加大對異地就醫(yī)結(jié)算過程中不法行為的懲治力度。
[Abstract]:Along with the economic development level of our country and people constantly improve the quality of life improved, how to live a decent life of dignity and mental health, has become a top priority for the government and the people's attention. In practice, health departments at all levels in our country, the Civil Affairs Department, made a series of efforts. From 1952 to the establishment of public medical security system and medical insurance system as the main body of the urban medical insurance system to date, China's medical insurance for urban workers, the new rural cooperative medical insurance (hereinafter referred to as the "new") and basic medical insurance for urban residents have been established, China's current implementation of the basic medical insurance coverage. In the legal construction of our country level. The medical insurance legal system and constantly improve the citizens' right to health care "and" human rights "has been written into the constitution of < >, < >" byelaw of inductrial injury insurance, social insurance law etc. Have been introduced. At present, the < < > constitution, social insurance law > law, China has initially established by insurance for urban workers, urban and rural residents and the new rural cooperative insurance as the main body of the basic medical insurance system. The problem is that, with the progress of social economy, China's floating population increasing the basic medical insurance, the insured places for the increasingly common phenomenon, but our country has not set up a unified system of basic medical insurance for.1998 years, the State Council promulgated the "decision on the establishment of" basic medical insurance system for urban employees (Guofa [1998]44), established the basic medical insurance for urban workers, the implementation of municipal co-ordination system. Under the guidance of this policy, urban residents medical insurance and NRCMS after all follow the design of the system of municipal co-ordination. One can not ignore the legal problems caused by the basic is: Due to low overall level of the medical insurance policy of "fragmentation", the insured can not enjoy a relatively fair and efficient medical treatment in remote medical treatment. Remote medical problems of equity and efficiency in the settlement process highlights. Except the introduction and conclusion, the thesis is divided into five parts. The first part is "the basic medical the insurance of remote medical billing and general analysis. Combined with the basic medical insurance system, analysis of this system under the different medical causes and remote medical billing. The phenomenon is around by the remote medical health resources distribution imbalance, caused by the common insured medical needs and uneven distribution of medical resources between the various reasons and contradictions of population flow. Remote medical billing is the basic medical insurance insured in the insurance area outside the medical diagnosis and treatment of patients after hospital treatment, the hospital and the social security agencies Between the settlement. At present, Chinese patients with different medical scale is growing rapidly, accordingly, remote medical insurance settlement scale expanding, subjects of remote medical insurance settlement requires more complex and diverse. The second part is the main legal problems of China's basic medical insurance settlement remote medical basic. The medical insurance system in China has the characteristic of "fragmentation", namely in different regions, the level of protection of basic medical insurance, there are many differences between the guarantee conditions and procedures, and remote medical billing and legal issues in the process of further analysis. First, the insured medical unfair problems highlighted on the one hand, the insured medical reimbursement for the treatment difference is too large, showing the different areas in the use of the insured to the same level of medical resources under the reimbursement level The same features. On the other hand, because of the authenticity of the remote settlement supervision difficult, health supervision departments to implement a more complicated but not on insurance fraud supervision effect reimbursement procedures, resulting in the cost of reimbursement should not be reimbursed, the insured shall be reasonable reimbursement costs difficult to reimbursement, which is not fair obviously the law-abiding insured. Second, real-time settlement remote medical system has not been fully established, most regional co-ordination of remote settlement procedures cumbersome, because the medical insurance settlement system is unreasonable, the insured in remote medical process actually bear a lot of unnecessary burden. The third part is the "causes" of the basic medical insurance for remote medical law the problem can be settled. The causes of the basic medical insurance settlement remote medical legal problems in boils down to two aspects: first, the basic medical insurance plan Low level. On the one hand, the level of basic medical insurance for urban workers in China's first low, followed by urban and rural residents and the new rural cooperative insurance is a continuation of the design of the system, has the historical characteristics of the overall level of the design of the basic medical insurance, has not made a breakthrough in the previous reform; on the other hand and the difference of economic development level among the regions of our country is large, but in our country, the finance management system on the basis of the fiscal transfer payment system has failed to effectively balance the allocation of medical resources, the characteristics of the basic medical insurance policy in China "fragmentation" is still very obvious. Second, basic medical insurance management and supervision system of remote medical billing not perfect. The main performance is: the lack of real-time settlement mechanism, remote medical billing and insurance fraud supervision subject confusion, remote medical billing and insurance fraud crackdown without judicial supervision Enough. The fourth part is the "study" the EU transnational medical billing system. The influences of the EU transnational medical management solutions can be found, the transnational medical management based on the coordination of health insurance policies, ensure the coordination of policies for EU citizens multinational medical fair and efficient there. On the one hand, policy coordination medical insurance to EU citizens should be fair and equal treatment principle; on the other hand, standardized management, unified multinational medical application form, the true meaning of the "one card" makes its citizens transnational medical settlement is extremely efficient. The fifth part is the "path" to break the basic medical insurance in other places in China the medical legal settlement. The author believes that the equalization of the arrangement of medical resources, improve the level of basic medical insurance, improve the basic medical insurance remote medical knot Management and supervision system, law helps to solve the problem of China's basic medical insurance remote medical billing appeared in the process. First, the equalization arrangement of medical resources, especially for local hospital treatment facilities, medical personnel balanced allocation of medical resources, can guide the insured fundamentally reasonable medical treatment, reduce the size of remote medical billing and resource consumption. In second, the implementation of the provincial level, the establishment of a regional coordination mechanism for remote medical billing. By means of financial transfer payment, the basic medical insurance policy unified province. Through signing remote medical billing protocol, the realization of the basic medical insurance policy of the convergence of regional economic development level. Third mutual recognition improve the basic medical insurance, medical system and the supervision and management of settlement, including the establishment of real-time settlement platform, to clarify the regulatory responsibilities of the main, and of other The punishment of unlawful acts in the course of medical settlement.

【學(xué)位授予單位】：西南政法大學(xué)
【學(xué)位級別】：碩士
【學(xué)位授予年份】：2015
【分類號】：D922.182.3

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