城镇职工基本医疗保险基金平衡的影响因素及对策研究
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摘要
研究背景
从上个世纪70年代以来，世界很多国家虽然社会保险模式的选择和发展情况各有不同，但都同样面临着一个共同难题，就是社会保险支出的过快增长。不论是支出增长的绝对额，还是社会保险支出与国内生产总值的比重，均表现出惊人的增长势头。很多国家的医疗保险发生了出险的情况，如日本，法国和西班牙等国家。我国也面临了同样的难题，近年来医疗费用的增长速度一直快于国民经济和职工工资的增长，这对我国以职工工资总额一定比例来筹资的医疗保险制度带来了很大的风险。
医疗保险基金能否收支平衡是医疗保险能否可持续发展的重要条件。因此，各地在医疗保险的运行过程中，保险基金的收支平衡始终是医保部门、医疗机构以及社会各部门关注的焦点问题之一。医疗保险基金的平衡受筹资和支出两方面的影响，任何影响其中一个或两个方面的因素都会对医疗保险基金的平衡产生影响。到2005年第二季度，19个省份中有169个统筹地区出现当期收不抵支，占统筹地区总数的7.3％，基金超支总额达1.7亿元，而且出险地区的个数和超支金额都还有继续增长的趋势，这对我国城镇职工基本医疗保险制度的可持续发展构成了巨大的风险。
本研究是由劳动和社会保障部医疗保险分会资助，是《中国城镇职工基本医疗保险筹资和费用的宏观影响因素及对策研究》课题的一部分。主要内容是深入研究影响医疗保险基金筹资和支出的各种直接或间接因素，分析其对基金平衡的影响作用，研究对这些因素如何进行控制和控制在什么程度才能保障基金的平衡运行。
研究目的
本研究通过对我国和所调查两市医疗保险的运行情况进行分析，深入研究医疗保险筹资和支付的增长规律，影响因素及其对基金平衡的作用，从而提出相应的增加筹资，控制支付过快增长的措施建议，为完善我国的城镇职工基本医疗保险制度提供参考。
研究方法
本研究主要应用卫生统计分析方法、卫生经济分析与评价方法、焦点组访谈方法以及卫生政策分析与评价方法等相关知识，采用定量和定性相结合的方法来进行研究。具体应用如下：
(1)经济学分析：对我国经济发展与卫生费用的增长规律进行比较分析。对医疗保险筹资和费用与人口经济的协调发展状况进行宏观经济学分析。
(2)运用卫生统计和卫生经济分析方法对医疗保险筹资和费用的影响因素及其作用大小进行分析，对医疗保险基金平衡进行预测。
(3)采用焦点组访谈的方法对从事医疗保险的工作人员和医院人员进行调查，了解他们对医疗保险制度的看法和意见，为确定合理的医疗保险政策提供依据。
(4)采用政策分析方法综合评价医疗保险基金平衡面临的问题，并针对这些问题提出相应的改进意见。
主要结果
1．国外的经验表明，卫生费用与国民经济可以在长时间内保持协调发展。而现在我国卫生总费用增长过快，与国民经济发展和居民收入增长水平不相适应，人们医疗保健支出的比例快速增长，医疗费用负担加重。
2．我国职工工资总额的增长率低于卫生总费用的增长率，而医疗费用的增长率略高于卫生费用的增长。因此对于我国按职工工资总额一定比例筹资的医疗保险制度来说，医疗保险基金面临超支的风险。
3．全国和所调查两城市的医疗保险基金运行情况都表明如下特点：医疗保险覆盖面还不够广，而且在现有制度下进一步扩面的空间不大；无论是总的医疗保险基金还是统筹基金都面临了支出增长率高于筹资增长率的情况，基金有超支的趋势，C市和H市人均统筹基金的弹性系数(支出增长率／筹资增长率)分别为1.89和2.32。
4．影响医疗保险基金筹资的直接因素有：缴费基数，缴费比例和在职退休人员比例。其中缴费基数与各项基金的人均筹资额呈正相关关系；在职职工比例在H市与人均统筹基金额呈正相关关系，在C市是非线性关系；缴费比例与人均医保基金额是正相关关系，与统筹基金和个人账户是非线性关系。
5．影响医疗保险人均统筹基金支出的因素主要有参保人员的年龄结构及住院率，次均住院费用、住院天数和医院级别。参保人员住院费用主要集中在50-70岁年龄组，三级医院发生的费用所占比例最大，基本在80％以上。
6．参保人员各级别医院人均费用的归因分析结果显示，两市二三级医院住院率对人均费用的贡献率最大，其次是次均费用，一级医院的归因分析的结果略有不同。两市在职和退休参保人员人均费用的归因分析结果基本一致，人均费用贡献率最大的是住院率，其次是次均费用。
7．两城市在保持现有的筹资和支付趋势下，医疗保险基金必将出现超支的情况。在对退休在职职工比例进行预测的基础上，可以得出当人们统筹基金支出比人均工资增长率高出3个百分点时，基金一般在10-15年间会出现超支的情况，如果高出6个百分点，基金会在5年左右出现超支的情况。
8．医疗保险部门与医疗卫生部门还需要进一步的相互协调，积极配合，并且要充分发挥社区卫生服务的作用。这对于减轻参保职工的经济负担、保护和满足老年人对基本医疗服务的需求目的、对于人口不断老龄化的C市和H市的基本医疗保险顺利运作，减轻医疗保险主管部门医疗保险费用负担将具有长远的积极意义。
政策建议
1．进一步提高医疗保障覆盖率水平
我国城镇职工基本医疗保险参保人数已达1.3亿多人，但也只覆盖了城市职工一半多(55％)。在目前的医疗保险政策下，进一步增加覆盖面的速度会降低。应在政策上有所突破，进一步扩大覆盖面。覆盖面的扩大不仅能够增加筹资，而且还可以有效改善人口年龄结构，分散医疗风险，对医疗保险基金的平衡起到有利的影响。在这个过程中需要注意的一个问题就是参保人员的逆向选择。
2．通过多种方式增加筹资额
在筹资方面，可以考虑以下几个建议：一是推迟退休年龄：二是提高筹资比例，但此为不得已而为之的策略；三是退休人员适度缴费。
3．加强对医院和医生的监督管理，探索合理的结算办法来控制医疗费用
医院和医生作为医疗服务的提供方在费用控制过程中起到关键作用。医疗消费的不确定性和医疗信息的不对称性使他成为医疗消费的主导方。对医院和医生应通过制定更为科学合理的费用支付方式加强供方行为的规范。
4．加强对医疗保险基金保值增值探索
逐步扩展医疗保险基金运作手段，扩宽基金运行渠道，可以增强医疗保险基金抵御风险的能力。
5．设立医疗保险风险基金
任何基金都有可能遇到风险，医疗保险基金也不例外，在面临一些难以控制的因素时，如发生了重大疾病流行，或老龄化高峰时期，通过采取许多积极措施后基金仍然难以平衡时，风险基金就可以用来帮助基金的平稳渡过。这对于医疗保险基金长期维持平衡具有重要的意义。
6．建立医疗保险预警系统
医疗保险基金的运行是动态的过程，如果能预测到基金超支会何时发生将会为采取相应措施争取时间，从而有可能避免超支的出现。建立医疗保险预警系统不仅只是在基金出现风险时起作用，也为医疗保险管理部门提供了基金运行的常规数据，利用这些数据可以为政策的完善提供参考。
7．完善医疗保险制度相关的各项法律
通过医疗保障立法对卫生费用的筹集、分配和利用进行明确规定，对保方、供方、需方及单位的责、权、利加以界定，使这一触及社会各方利益格局社会政策长期平稳运行有更高的制度保证。
创新之处
1．通过对OECD国家卫生总费用和国民经济、人们收入增长规律的比较分析，证
Background
Since 1970s, many countries in the world have suffered the same problem --
excessive increase of social insurance expenditure though they varied in social insurance pattern and developed in different way. The absolute number of increasing expenditure as well as the ratio of social insurance expense to GDP has presented a surprisingly increasing momentum. In some countries, such as Japan, France and Spain, it has occurred the situation that funds expense has overweighed revenue. Our conntry also face the same problem, the increasing speed of medical expenditure is more fast that of GDP and salary income per capital. It brings great risk on our medical insurance which funds is collected based on salary.
Funds of medical insurance is the basis of implementing medical insurance. Whether the funds can keep balance or not is imperative to the sustainable development of medical insurance. Therefore, keeping funds' balance has always been the focus of medical insurance institutions, health care providers and other relative institutions. Two aspects, revenue and expenditure, will influence the balance of funds. In second quarter of 2005, the expenditure have exceeded the revenue in 169 cities, whick accounts to 7.3% of the total cities where have implemented medical insurance. The entire overspending amount was up to 170million RMB. There is a tendency that the numbers of these cities and the overspending amount will be on the rise in the future, which presents severe challenge to the sustainable development of basic medical insurance system.
This research has been sponsored by the China Social Insurance Association Medical Insurance Branch and is a part of the project of Macro influencing factors on the revenue and expenditure of basic medical insurance. The research contents include to research the direct or indirect effecting factors concerning the revenue and expenditure of medical insurance funds, analyze their impact on keeping funds' balance and how to control them.
Objectives
By analyzing implementation of medical insurance in C and H cities, and researching the increasing rule of revenue and expenditure, and the influencing factors of keeping funds' balance, to bring out the suitable advises of increasing revenue and conrtroling expenditure, and provide evidence for proposing rational policy. Methods
In this research, quantity and quality study methods such as health statistic analysis, health economic analysis, focus group interview and health policy analysis have been employed. They are used as follows.
(1)Economic analysis. We have used economic method to compare the increasing health expense to the economic growth, and have analyzed the financing and expenditure of medical insurance and the harmonious development of population and economy from macroeconomic perspective.
(2)We have used health statistic approach and health economic approach to study the influencing factors and their effect, and have estimated the implementation of funds.
(3)We have organized focus group interview to investigate relative stuff, acquiring their opinions concerning medical insurance, so that provided evidence for proposing rational policy.
(4)We have used policy analysis approach to evaluate the problems confronted with medical insurance in a comprehensive way and have presented corresponding solution.
Main results
1. We have found out that total health expenditure (THE) can be increased harmoniously with GDP and salary in long phase. Now the increase of THE has overspeeded the GDP and salary. The fast increase of medical expense has made the disease burden more heavily.
2. We have also found out that the increase rate of total salary income was lower than that of THE. While the increase rate of medical expenditure was a little bit higher than that of the THE. Therefore, in terms of medical insurance whose financing is dependent on the total salary income, funds are confronted with the risk of expenditure exceeding financing.
3. By investigating the two cities and other cities all over the country, the implementation of funds demonstrated such characteristics as follows. The coverage was not extensive enough and the expanding potential under existing system is not strong. Both the total funds and the unified medical fund (UMF) of the medical insurance have experienced the higher expenditure increasing rate than those of financing, and funds have shown a tendency of overbalance. In city C and H, the elasticity coefficients (expenditure increasing rate to financing increasing rate ) of UMF per capita were 1.89 and 2.32 respectively.
4. We have concluded that the salary income, the premium rate and the proportion of employees are the direct influencing factors on funds financing. The salary income has positive relation with UMF per capita. In city, H The UMF per capita has positive relation with the proportion of employees while in city C there is no linear relation between each other. The premium rate also has positive relation with medical insurance funds per capita, and the UMF has no linear relation with personal account. 5. The influencing factors concerning the funds expenditure are as follows: age structure of participants, hospitalization rate, hospitalization expense per time, stay days in hospital and the level of hospital. We have found out that the main expense of hospitalization was by the age group of 50 to 70. And the majority expense occurred in tertiary hospitals, accounting more than 80%.
6. By using attribution analysis on the medical expense per capita in hospitals of all levels, we have found out that the contribution rate of hospitalization rate in secondary and tertiary hospitals in two cities ranked first, and the hospitalization expense per time ranked second. The attribution analysis on primary hospitals was different in two cities. While the attribution analysis on employees' and retirees' medical expense per capita was the same, with hospitalization rate ranking first and medical expense per time ranking second.
7. The existing tendency of financing and expenditure in the two cities will lead to overbalance of funds. By estimating the employee to retiree ratio we have concluded that if the increasing rate of funds' expenditure per capita was 3% higher than salary income, funds' financing would exceed expenditure in 10 to 15 years. And if 6% higher, funds' overbalance would occur in 5 years.
8. We also suggested that medical insurance institutes and health care provider should coordinate with each other and the health care in community should be played in full. It will be significant for reducing participants' economic burden, meeting aged people's medical needs and relieving the pressure of fund's balance in the aging population society.
Suggestions
1.Further expending coverage of insurance.
Currently, the participants of basic medical insurance in our country are over 130million. However, it had only covered 55% of the entire employees in urban areas. Under existing medical insurance policy, the process of expanding coverage will be slowed down. We should make break through in policy to expand coverage. It will not only increase funds' revenue but also help to improve participants' age structure, share medical risks and keep funds' balance. In this course, participants' reserved choices deserve attention. 2.0pening more channels to increase revenue of funds.
As far as financing is concerned, we recommend solutions as follows. Firstly, delaying the time of retirement .Secondly, raising the proportion of financing .At last, the retirees should also pay premium in some extent.
3.Strenthening supervision on hospitals and doctors and exploring rational payment methods to control medical expenditure.
Hospitals and doctors, as the health care providers, play a crucial role in controlling medical expenditure. Uncertainty of medical consumption and unsymmetry of medical information make health care provider become the dominating part of medical consumption. We should foster rational payment method to regulate provider's behavior.
4.Futher exploring approach to reserve and raise the funds' value. We should broaden
the implementation way of funds to strengthen funds' ability to protect risks.
5.Setting up risk funds.
All funds have risks and the funds of medical insurance are without exception. When meeting with some uncontrollable factors, such as epidemic, the peak of aging population, risk funds will help balance the funds of medical insurance. It will be significant to the funds' sustainable balance. 6.Building pre-alarm system.
The implementation of funds is a dynamic process. If we can forecast the time when the funds' revenue will exceed the expenditure and take corresponding action, we may avoid the occurrence of funds' overbalance. Building pre-alarm system is not only useful when there's risk in funds, but also provides regular data for medical insurance institute to improve policy. 7.Improving relative law.
We should legislate to make clear regulation on financing, allocation and utilization of health expenditure and define the responsibility, rights and interests of all parties which will guarantee the steady implementation of medical insurance system in the long term.
从上个世纪70年代以来，世界很多国家虽然社会保险模式的选择和发展情况各有不同，但都同样面临着一个共同难题，就是社会保险支出的过快增长。不论是支出增长的绝对额，还是社会保险支出与国内生产总值的比重，均表现出惊人的增长势头。很多国家的医疗保险发生了出险的情况，如日本，法国和西班牙等国家。我国也面临了同样的难题，近年来医疗费用的增长速度一直快于国民经济和职工工资的增长，这对我国以职工工资总额一定比例来筹资的医疗保险制度带来了很大的风险。
医疗保险基金能否收支平衡是医疗保险能否可持续发展的重要条件。因此，各地在医疗保险的运行过程中，保险基金的收支平衡始终是医保部门、医疗机构以及社会各部门关注的焦点问题之一。医疗保险基金的平衡受筹资和支出两方面的影响，任何影响其中一个或两个方面的因素都会对医疗保险基金的平衡产生影响。到2005年第二季度，19个省份中有169个统筹地区出现当期收不抵支，占统筹地区总数的7.3％，基金超支总额达1.7亿元，而且出险地区的个数和超支金额都还有继续增长的趋势，这对我国城镇职工基本医疗保险制度的可持续发展构成了巨大的风险。
本研究是由劳动和社会保障部医疗保险分会资助，是《中国城镇职工基本医疗保险筹资和费用的宏观影响因素及对策研究》课题的一部分。主要内容是深入研究影响医疗保险基金筹资和支出的各种直接或间接因素，分析其对基金平衡的影响作用，研究对这些因素如何进行控制和控制在什么程度才能保障基金的平衡运行。
研究目的
本研究通过对我国和所调查两市医疗保险的运行情况进行分析，深入研究医疗保险筹资和支付的增长规律，影响因素及其对基金平衡的作用，从而提出相应的增加筹资，控制支付过快增长的措施建议，为完善我国的城镇职工基本医疗保险制度提供参考。
研究方法
本研究主要应用卫生统计分析方法、卫生经济分析与评价方法、焦点组访谈方法以及卫生政策分析与评价方法等相关知识，采用定量和定性相结合的方法来进行研究。具体应用如下：
(1)经济学分析：对我国经济发展与卫生费用的增长规律进行比较分析。对医疗保险筹资和费用与人口经济的协调发展状况进行宏观经济学分析。
(2)运用卫生统计和卫生经济分析方法对医疗保险筹资和费用的影响因素及其作用大小进行分析，对医疗保险基金平衡进行预测。
(3)采用焦点组访谈的方法对从事医疗保险的工作人员和医院人员进行调查，了解他们对医疗保险制度的看法和意见，为确定合理的医疗保险政策提供依据。
(4)采用政策分析方法综合评价医疗保险基金平衡面临的问题，并针对这些问题提出相应的改进意见。
主要结果
1．国外的经验表明，卫生费用与国民经济可以在长时间内保持协调发展。而现在我国卫生总费用增长过快，与国民经济发展和居民收入增长水平不相适应，人们医疗保健支出的比例快速增长，医疗费用负担加重。
2．我国职工工资总额的增长率低于卫生总费用的增长率，而医疗费用的增长率略高于卫生费用的增长。因此对于我国按职工工资总额一定比例筹资的医疗保险制度来说，医疗保险基金面临超支的风险。
3．全国和所调查两城市的医疗保险基金运行情况都表明如下特点：医疗保险覆盖面还不够广，而且在现有制度下进一步扩面的空间不大；无论是总的医疗保险基金还是统筹基金都面临了支出增长率高于筹资增长率的情况，基金有超支的趋势，C市和H市人均统筹基金的弹性系数(支出增长率／筹资增长率)分别为1.89和2.32。
4．影响医疗保险基金筹资的直接因素有：缴费基数，缴费比例和在职退休人员比例。其中缴费基数与各项基金的人均筹资额呈正相关关系；在职职工比例在H市与人均统筹基金额呈正相关关系，在C市是非线性关系；缴费比例与人均医保基金额是正相关关系，与统筹基金和个人账户是非线性关系。
5．影响医疗保险人均统筹基金支出的因素主要有参保人员的年龄结构及住院率，次均住院费用、住院天数和医院级别。参保人员住院费用主要集中在50-70岁年龄组，三级医院发生的费用所占比例最大，基本在80％以上。
6．参保人员各级别医院人均费用的归因分析结果显示，两市二三级医院住院率对人均费用的贡献率最大，其次是次均费用，一级医院的归因分析的结果略有不同。两市在职和退休参保人员人均费用的归因分析结果基本一致，人均费用贡献率最大的是住院率，其次是次均费用。
7．两城市在保持现有的筹资和支付趋势下，医疗保险基金必将出现超支的情况。在对退休在职职工比例进行预测的基础上，可以得出当人们统筹基金支出比人均工资增长率高出3个百分点时，基金一般在10-15年间会出现超支的情况，如果高出6个百分点，基金会在5年左右出现超支的情况。
8．医疗保险部门与医疗卫生部门还需要进一步的相互协调，积极配合，并且要充分发挥社区卫生服务的作用。这对于减轻参保职工的经济负担、保护和满足老年人对基本医疗服务的需求目的、对于人口不断老龄化的C市和H市的基本医疗保险顺利运作，减轻医疗保险主管部门医疗保险费用负担将具有长远的积极意义。
政策建议
1．进一步提高医疗保障覆盖率水平
我国城镇职工基本医疗保险参保人数已达1.3亿多人，但也只覆盖了城市职工一半多(55％)。在目前的医疗保险政策下，进一步增加覆盖面的速度会降低。应在政策上有所突破，进一步扩大覆盖面。覆盖面的扩大不仅能够增加筹资，而且还可以有效改善人口年龄结构，分散医疗风险，对医疗保险基金的平衡起到有利的影响。在这个过程中需要注意的一个问题就是参保人员的逆向选择。
2．通过多种方式增加筹资额
在筹资方面，可以考虑以下几个建议：一是推迟退休年龄：二是提高筹资比例，但此为不得已而为之的策略；三是退休人员适度缴费。
3．加强对医院和医生的监督管理，探索合理的结算办法来控制医疗费用
医院和医生作为医疗服务的提供方在费用控制过程中起到关键作用。医疗消费的不确定性和医疗信息的不对称性使他成为医疗消费的主导方。对医院和医生应通过制定更为科学合理的费用支付方式加强供方行为的规范。
4．加强对医疗保险基金保值增值探索
逐步扩展医疗保险基金运作手段，扩宽基金运行渠道，可以增强医疗保险基金抵御风险的能力。
5．设立医疗保险风险基金
任何基金都有可能遇到风险，医疗保险基金也不例外，在面临一些难以控制的因素时，如发生了重大疾病流行，或老龄化高峰时期，通过采取许多积极措施后基金仍然难以平衡时，风险基金就可以用来帮助基金的平稳渡过。这对于医疗保险基金长期维持平衡具有重要的意义。
6．建立医疗保险预警系统
医疗保险基金的运行是动态的过程，如果能预测到基金超支会何时发生将会为采取相应措施争取时间，从而有可能避免超支的出现。建立医疗保险预警系统不仅只是在基金出现风险时起作用，也为医疗保险管理部门提供了基金运行的常规数据，利用这些数据可以为政策的完善提供参考。
7．完善医疗保险制度相关的各项法律
通过医疗保障立法对卫生费用的筹集、分配和利用进行明确规定，对保方、供方、需方及单位的责、权、利加以界定，使这一触及社会各方利益格局社会政策长期平稳运行有更高的制度保证。
创新之处
1．通过对OECD国家卫生总费用和国民经济、人们收入增长规律的比较分析，证
Background
Since 1970s, many countries in the world have suffered the same problem --
excessive increase of social insurance expenditure though they varied in social insurance pattern and developed in different way. The absolute number of increasing expenditure as well as the ratio of social insurance expense to GDP has presented a surprisingly increasing momentum. In some countries, such as Japan, France and Spain, it has occurred the situation that funds expense has overweighed revenue. Our conntry also face the same problem, the increasing speed of medical expenditure is more fast that of GDP and salary income per capital. It brings great risk on our medical insurance which funds is collected based on salary.
Funds of medical insurance is the basis of implementing medical insurance. Whether the funds can keep balance or not is imperative to the sustainable development of medical insurance. Therefore, keeping funds' balance has always been the focus of medical insurance institutions, health care providers and other relative institutions. Two aspects, revenue and expenditure, will influence the balance of funds. In second quarter of 2005, the expenditure have exceeded the revenue in 169 cities, whick accounts to 7.3% of the total cities where have implemented medical insurance. The entire overspending amount was up to 170million RMB. There is a tendency that the numbers of these cities and the overspending amount will be on the rise in the future, which presents severe challenge to the sustainable development of basic medical insurance system.
This research has been sponsored by the China Social Insurance Association Medical Insurance Branch and is a part of the project of Macro influencing factors on the revenue and expenditure of basic medical insurance. The research contents include to research the direct or indirect effecting factors concerning the revenue and expenditure of medical insurance funds, analyze their impact on keeping funds' balance and how to control them.
Objectives
By analyzing implementation of medical insurance in C and H cities, and researching the increasing rule of revenue and expenditure, and the influencing factors of keeping funds' balance, to bring out the suitable advises of increasing revenue and conrtroling expenditure, and provide evidence for proposing rational policy. Methods
In this research, quantity and quality study methods such as health statistic analysis, health economic analysis, focus group interview and health policy analysis have been employed. They are used as follows.
(1)Economic analysis. We have used economic method to compare the increasing health expense to the economic growth, and have analyzed the financing and expenditure of medical insurance and the harmonious development of population and economy from macroeconomic perspective.
(2)We have used health statistic approach and health economic approach to study the influencing factors and their effect, and have estimated the implementation of funds.
(3)We have organized focus group interview to investigate relative stuff, acquiring their opinions concerning medical insurance, so that provided evidence for proposing rational policy.
(4)We have used policy analysis approach to evaluate the problems confronted with medical insurance in a comprehensive way and have presented corresponding solution.
Main results
1. We have found out that total health expenditure (THE) can be increased harmoniously with GDP and salary in long phase. Now the increase of THE has overspeeded the GDP and salary. The fast increase of medical expense has made the disease burden more heavily.
2. We have also found out that the increase rate of total salary income was lower than that of THE. While the increase rate of medical expenditure was a little bit higher than that of the THE. Therefore, in terms of medical insurance whose financing is dependent on the total salary income, funds are confronted with the risk of expenditure exceeding financing.
3. By investigating the two cities and other cities all over the country, the implementation of funds demonstrated such characteristics as follows. The coverage was not extensive enough and the expanding potential under existing system is not strong. Both the total funds and the unified medical fund (UMF) of the medical insurance have experienced the higher expenditure increasing rate than those of financing, and funds have shown a tendency of overbalance. In city C and H, the elasticity coefficients (expenditure increasing rate to financing increasing rate ) of UMF per capita were 1.89 and 2.32 respectively.
4. We have concluded that the salary income, the premium rate and the proportion of employees are the direct influencing factors on funds financing. The salary income has positive relation with UMF per capita. In city, H The UMF per capita has positive relation with the proportion of employees while in city C there is no linear relation between each other. The premium rate also has positive relation with medical insurance funds per capita, and the UMF has no linear relation with personal account. 5. The influencing factors concerning the funds expenditure are as follows: age structure of participants, hospitalization rate, hospitalization expense per time, stay days in hospital and the level of hospital. We have found out that the main expense of hospitalization was by the age group of 50 to 70. And the majority expense occurred in tertiary hospitals, accounting more than 80%.
6. By using attribution analysis on the medical expense per capita in hospitals of all levels, we have found out that the contribution rate of hospitalization rate in secondary and tertiary hospitals in two cities ranked first, and the hospitalization expense per time ranked second. The attribution analysis on primary hospitals was different in two cities. While the attribution analysis on employees' and retirees' medical expense per capita was the same, with hospitalization rate ranking first and medical expense per time ranking second.
7. The existing tendency of financing and expenditure in the two cities will lead to overbalance of funds. By estimating the employee to retiree ratio we have concluded that if the increasing rate of funds' expenditure per capita was 3% higher than salary income, funds' financing would exceed expenditure in 10 to 15 years. And if 6% higher, funds' overbalance would occur in 5 years.
8. We also suggested that medical insurance institutes and health care provider should coordinate with each other and the health care in community should be played in full. It will be significant for reducing participants' economic burden, meeting aged people's medical needs and relieving the pressure of fund's balance in the aging population society.
Suggestions
1.Further expending coverage of insurance.
Currently, the participants of basic medical insurance in our country are over 130million. However, it had only covered 55% of the entire employees in urban areas. Under existing medical insurance policy, the process of expanding coverage will be slowed down. We should make break through in policy to expand coverage. It will not only increase funds' revenue but also help to improve participants' age structure, share medical risks and keep funds' balance. In this course, participants' reserved choices deserve attention. 2.0pening more channels to increase revenue of funds.
As far as financing is concerned, we recommend solutions as follows. Firstly, delaying the time of retirement .Secondly, raising the proportion of financing .At last, the retirees should also pay premium in some extent.
3.Strenthening supervision on hospitals and doctors and exploring rational payment methods to control medical expenditure.
Hospitals and doctors, as the health care providers, play a crucial role in controlling medical expenditure. Uncertainty of medical consumption and unsymmetry of medical information make health care provider become the dominating part of medical consumption. We should foster rational payment method to regulate provider's behavior.
4.Futher exploring approach to reserve and raise the funds' value. We should broaden
the implementation way of funds to strengthen funds' ability to protect risks.
5.Setting up risk funds.
All funds have risks and the funds of medical insurance are without exception. When meeting with some uncontrollable factors, such as epidemic, the peak of aging population, risk funds will help balance the funds of medical insurance. It will be significant to the funds' sustainable balance. 6.Building pre-alarm system.
The implementation of funds is a dynamic process. If we can forecast the time when the funds' revenue will exceed the expenditure and take corresponding action, we may avoid the occurrence of funds' overbalance. Building pre-alarm system is not only useful when there's risk in funds, but also provides regular data for medical insurance institute to improve policy. 7.Improving relative law.
We should legislate to make clear regulation on financing, allocation and utilization of health expenditure and define the responsibility, rights and interests of all parties which will guarantee the steady implementation of medical insurance system in the long term.
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