發(fā)布時間：2018-05-14 20:38

  本文選題：基本醫(yī)療保險制度 + 城鄉(xiāng)居民醫(yī)保整合�。� 參考：《山東大學》2017年碩士論文

【摘要】：研究背景建國以來,我國的居民基本醫(yī)療保險體系建立在城鄉(xiāng)二元社會經(jīng)濟發(fā)展差異化的基礎上,制度建設呈現(xiàn)出多元化、碎片化的不良特征。隨著社會經(jīng)濟的發(fā)展,不同醫(yī)療保險制度帶來的城鄉(xiāng)間的不平等弊端日益凸顯。城鎮(zhèn)居民醫(yī)保和新農(nóng)合制度,分屬不同的管理部門,籌資、保障水平差距大,與保障城鄉(xiāng)居民健康權(quán)益的公平性及實現(xiàn)全民醫(yī)保制度的目標不相適應,對于社會保障制度的持續(xù)健康發(fā)展產(chǎn)生了不利影響,整合城鄉(xiāng)居民基本醫(yī)療保險制度成為經(jīng)濟社會發(fā)展的必然。為此,國務院和黨的十八大均提出了消除城鄉(xiāng)差別、實現(xiàn)城鄉(xiāng)醫(yī)保制度一體化發(fā)展的要求,2016年《國務院關于整合城鄉(xiāng)居民基本醫(yī)療保險制度的意見》更是對各省開展城鎮(zhèn)居民醫(yī)保和新農(nóng)合制度的整合工作進行了明確規(guī)定和部署。山東省于2014年開始在全省推行城鄉(xiāng)居民醫(yī)保制度的整合工作,2015年實行城鄉(xiāng)統(tǒng)一的居民基本醫(yī)療保險制度,但尚未開展城鄉(xiāng)居民醫(yī)保整合效果的評估工作。為及時總結(jié)城鄉(xiāng)居民醫(yī)保整合過程中的問題,進一步完善醫(yī)保整合制度,有必要對整合過程及效果進行系統(tǒng)評價,以保障城鄉(xiāng)居民醫(yī)保制度運行的健康和可持續(xù)性。研究意義與目的對山東省的城鄉(xiāng)居民醫(yī)保整合效果進行系統(tǒng)評價,意在及時總結(jié)山東省醫(yī)保整合的成效和問題,為山東省城鄉(xiāng)醫(yī)保整合工作的進一步改進提供策略建議,這對居民醫(yī)保制度的建設和持續(xù)發(fā)展具有重要意義。同時,通過研究構(gòu)建醫(yī)保整合效果的評價指標體系,能夠彌補目前城鄉(xiāng)居民醫(yī)保整合系統(tǒng)評價研究的空缺并為其他省市開展城鄉(xiāng)醫(yī)保整合評價提供依據(jù)。本研究的主要目的是通過構(gòu)建評價指標體系,系統(tǒng)評價山東省城鄉(xiāng)居民醫(yī)保整合各個環(huán)節(jié)的效果,明確醫(yī)保整合的具體成效和問題,為進一步完善城鄉(xiāng)居民醫(yī)保整合工作提供政策建議。研究方法利用“結(jié)構(gòu)-過程-結(jié)果”評價理論、德爾菲專家法、層次分析法完成評價指標體系的構(gòu)建。抽取了東營、威海、淄博、臨沂、濟寧5個樣本市進行研究,并于樣本市分層隨機抽取了樣本醫(yī)保管理經(jīng)辦機構(gòu)、醫(yī)療機構(gòu)和參保居民家庭,進行問卷調(diào)查和訪談,獲取所需數(shù)據(jù)資料。依據(jù)制定的"評分細則"對樣本市指標進行打分并計算評價結(jié)果。研究結(jié)果1.城鄉(xiāng)居民醫(yī)保整合效果評價指標體系構(gòu)建結(jié)果:研究確立了由“制度建設情況”、“制度落實情況”、“制度實施效果” 3個一級指標以及11個二級指標、30個三級指標組成的滿分為10分的量化整合效果評價指標體系。2.城鄉(xiāng)居民醫(yī)保整合效果評價結(jié)果:從總體評價結(jié)果來看,樣本市中東營的效果評價總得分在8分以上,其余4市總得分在7.5以上,在較短的整合時間內(nèi),山東省的城鄉(xiāng)居民醫(yī)保整合取得了一定成效。制度建設情況指標得分較高,制度落實情況和制度實施效果部分的指標則相對失分較多。從樣本市之間的評價結(jié)果來看,東營總體得分最高,且三個一級指標的得分均為最高;濟寧的總體得分最低,比總得分最高的東營低了 16.33個百分點。樣本市之間的總體得分差距較大。樣本市之間,制度建設指標得分基本一致,相差不大;制度落實指標得分有一定差距,醫(yī)保整合的制度落實效果存在差異；制度實施效果指標得分差距較大。討論與建議山東省城鄉(xiāng)居民醫(yī)保整合已在整體上取得一定成效,但目前醫(yī)保整合尚存在諸多亟待解決的問題。在城鄉(xiāng)居民醫(yī)保整合的制度建設方面,基本制度建設較為完備,但醫(yī)保經(jīng)辦管理體系建設尚不完善,大病與基本醫(yī)保管辦分離,管理體制尚未理順。制度落實方面,籌資、補償制度落實較好,但地域間居民醫(yī)保整合制度的落實存在差異,基金管理和監(jiān)督制度部分缺位,基金運行存在風險。制度實施效果方面,制度覆蓋全面,參保居民受益程度提高且滿意度較高,但醫(yī)保制度對居民醫(yī)療服務分流的引導作用不明顯,醫(yī)療費用過快增長抵減了醫(yī)保制度抵御疾病經(jīng)濟風險的作用,居民對醫(yī)保制度的認識不到位,影響制度的落實效果。為此提出進一步完善山東省城鄉(xiāng)居民醫(yī)保整合的建議:加強醫(yī)保管理隊伍建設;理順大病醫(yī)保管理體制;加強對醫(yī)保制度運行的監(jiān)管;強化醫(yī)保制度對醫(yī)藥服務的政策導向；加大對醫(yī)保整合的宣傳力度。
[Abstract]:The basic medical insurance system of the residents in China has been established on the basis of the difference in the social and economic development of two yuan in urban and rural areas since the founding of the people's Republic of China. The system construction has shown a diversity and fragmented bad characteristics. With the development of the social economy, the unequal malpractices of urban and rural areas brought by different medical insurance systems are becoming increasingly prominent. The system of conservation and new rural cooperation belongs to the different management departments, the financing and the security level gap is large. It does not adapt to the goal of ensuring the equity of the health rights and interests of urban and rural residents and the goal of realizing the universal medical insurance system. It has a negative impact on the sustainable and healthy development of the social security system. The basic medical insurance system of urban and rural residents has become an economic society. To this end, the State Council and the eighteen Party of the party all put forward the requirements to eliminate urban and rural differences and realize the integration of urban and rural medical insurance system. In 2016, the State Council on the integration of urban and rural residents' basic medical insurance system was more specific to the integration of medical insurance and NCMS in the provinces. In 2014, Shandong province began to implement the integration of urban and rural residents' medical insurance system in the province. In 2015, the basic medical insurance system of urban and rural residents was implemented, but the evaluation of the integration effect of medical insurance for urban and rural residents has not been carried out. In order to summarize the problems in the process of medical insurance integration in urban and rural residents in time, further improve the integration of medical insurance. System, it is necessary to systematically evaluate the integration process and effect in order to ensure the health and sustainability of the medical insurance system of urban and rural residents. The significance and purpose of the research on the integration effect of medical insurance in urban and rural residents in Shandong province is systematically evaluated. It is intended to summarize the effectiveness and problems of the integration of medical insurance in Shandong Province in time, for the integration of medical insurance in urban and rural areas in Shandong province. Further improvement provides strategic suggestions, which is of great significance to the construction and sustainable development of medical insurance system for residents. At the same time, through the research and construction of the evaluation index system for the integration effect of medical insurance, it can make up the vacancy of the evaluation and Research on the medical insurance integration system of urban and rural residents and provide the basis for other provinces and cities to carry out the integration evaluation of medical insurance in urban and rural areas. The main purpose of this study is to systematically evaluate the effects of the integration of medical insurance in urban and rural residents in Shandong province by constructing the evaluation index system, to make clear the specific results and problems of medical insurance integration, and to provide policy suggestions for further improvement of medical insurance integration in urban and rural residents. The evaluation index system was constructed by the analytic hierarchy process (AHP). 5 samples of Dongying, Weihai, Zibo, Linyi and Jining were studied, and the sample medical insurance management agencies, medical institutions and the insured households were randomly selected from the sample city. The data were obtained by questionnaire survey and interview. The determined "scoring rules" score the sample city indicators and calculate the evaluation results. Results 1. the results of the evaluation index system of the medical insurance integration effect of urban and rural residents: the study established the 3 first levels of "system construction", "system implementation", "system implementation effect", and 11 two level indicators, and 30 three level indicators. The result of the evaluation of medical insurance integration effect of urban and rural residents with a full score of 10 points of quantitative integration effect evaluation index system.2.: from the overall evaluation results, the total score of the effect evaluation of the middle east battalion in the sample city is above 8 points, the total score of the other 4 cities is above 7.5. In the short integration time, the medical insurance integration of the urban and rural residents in Shandong province has been obtained. The system construction index score is high, the system implementation situation and the system implementation effect part are relatively lost. From the evaluation results of the sample City, Dongying has the highest overall score, and the three first grade indexes are the highest, the Jining total body score is the lowest, which is 16. lower than the Dongying with the highest total score. 33 percentage points. The overall score gap between the sample cities is large. Among the sample cities, the system construction index scores are basically the same, the difference is small; the system implementation indicators have a certain gap, the system implementation effect of the medical insurance integration is different; the system implementation effect index score difference is large. Discussion and suggestion on the medical insurance of urban and rural residents in Shandong Province The integration has achieved certain results in the whole, but there are still many problems to be solved in the integration of medical insurance. In the system construction of medical insurance integration of urban and rural residents, the construction of basic system is relatively complete, but the construction of the management system of medical insurance management system is not perfect, the major diseases and basic medical insurance management system are separated, the management system has not been straightened out. There are differences in the implementation of medical insurance integration system among regional residents, the lack of fund management and supervision system and the risk of fund operation. The effect of medical insurance system against the risk of disease economy is reduced by the rapid growth of medical expenses, and the residents' understanding of the medical insurance system is not in place, and the effect of the system is affected. Therefore, the suggestion of further perfecting the integration of medical insurance in urban and rural residents in Shandong province is put forward: strengthening the construction of medical insurance management team and straightening out the medical insurance management of the great disease. We should strengthen supervision over the operation of the medical insurance system, strengthen the policy orientation of the medical insurance system for medical services, and intensify publicity efforts on the integration of medical insurance.

【學位授予單位】：山東大學
【學位級別】：碩士
【學位授予年份】：2017
【分類號】：R197.1;F842.684

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