潍坊市城镇职工医疗保险制度改革存在的问题与对策研究
摘要
在人类面临的诸多风险中,疾病风险危害严重、涉及面广、复杂多样,是直接关系到人类基本生存利益的特殊风险。同时,随着现代疾病复杂性的增加、人类健康观念的改变、以及医疗技术的不断进步、医疗费用的急剧膨胀,使得基本医疗保险成为世界性的难题。潍坊市城镇职工基本医疗保险制度实施时间不长,以及基本医疗保险工作本身的复杂性,所以目前在基本医疗保险方面出现了各种各样的问题。
一是个人费用负担重。实施几年来,个人所负担的医疗费用占医疗总费用的比例平均为30%,整体上有一定幅度的上涨,尤其是国家机关公务员及原来经济效益较好的企、事业单位人员更是感觉医疗保险待遇有明显下降。
二是医疗保险“扩面难”。一部分经济效益好、完全具备缴费能力的单位不愿参保,而又有一部分经济效益差、不具备缴费能力的单位不能参保。
三是存在道德风险。医疗供应方的道德风险和需求方的道德风险,导致了医疗保险基金尤其是统筹基金发生一定程度的流失。
四是基本医疗保险个人帐户效率低下。个人账户化解医疗费用风险的能力弱,管理成本高,面临贬值风险。
五是缴费年限与医疗待遇尚未挂钩。不管个人缴纳医疗保险费的多少、缴费年限的长短,享受无差别的医疗保险待遇。
六是未实行基本医疗保险最低缴费年限,退休人员享受基本医疗保险待遇与单位缴费情况挂钩。退休人员因原单位缴费不及时或无力缴费而享受不到正常的医疗待遇。完善潍坊市市级基本医疗保险制度的对策:
一是要确立全新的基本医疗保险理念。基本医疗保险的水平要与我国社会主义初级阶段的生产力发展水平相适应。现阶段就要根据我们的国情,实事求是地采取国家、集体、个人共同承担医疗保险的政策。
二是强化政府的职责。及时调整基本医疗保险“三个目录”,大力发展社区卫生服务网络,加强推进单病种结算,大力发展管理式医疗计划,采取切实措施扩大基本医疗保险覆盖面。
三是通过加强个人现金支付,建立全民健康保险,加快医疗卫生体制改革和药品流通体制改革,医保办医院等措施,防范医疗需求方和供应方的道德风险。
四是淡化并最终取消基本医疗保险个人帐户。
五是预防基金赤字风险。加强医疗保险基金运行情况的分析和预测,规范基金财务管理制度,提高统筹层次,提高医疗保险基金征缴率,加强基本保险基金支出管理,建立基本医疗保险后备金制度。
六是实行基本医疗保险最低缴费年限制度,缴费年限与医疗待遇挂钩。
In the many risks facing humanity, the disease risk serious harm, covers a wide range of complex and diverse, is directly related to basic human survival interests of the special risks. At the same time, as modern increase in the complexity of the disease, human health, the concept of change, as well as medical technology continues to progress, the rapid expansion of health care costs, making the basic medical insurance has become a world problem. The Weifang cities staff basic medical insurance system implementation time is not long, as well as basic medical insurance work's complexity, therefore present had various problems in the basic medical insurance aspect.
First, the heavy burden of personal cost. Implemented over the past few years, the personal burden of medical expenses for the proportion of the total medical costs an average of 30 percent, the overall rate of increase to a certain extent, especially the civil service and state organs, the better the original economic enterprises, institutions, the medical staff is feeling insurance benefits have decreased significantly.
Second, medical insurance "extended surface difficult." Part of good economic returns, complete with the ability to pay to unit holders, and they have the economic part of poor, and do not have the ability to pay can not be insured units.
Third, the existence of moral hazard. Medical supply-side and demand-side moral risks of moral hazard, leading to a health insurance fund is to co-ordinate fund especially in a certain degree of wastage.
Fourth, the basic medical insurance personal accounts inefficient.
Individual accounts defuse the risk of medical costs, low management costs are high, facing the devaluation risk.
Fifth, the payment age limit and the medical treatment not yet link up. No matter individual payment medical service insurance premium's how many, the payment age limit's length, enjoys the non-difference the medical insurance treatment.
Sixth, it is the failure to implement the basic medical insurance payment minimum age, retired workers enjoy basic medical insurance benefits and the payment of premiums linked units. Retirees do not pay for the original unit or inability to timely payment and could not enjoy a normal medical treatment. Weifang City municipal improve the basic medical insurance system responses:
First, must establish the brand-new basic medical insurance idea. The basic medical insurance's level must adapt with our country socialism initial stage productive forces level of development. The present stage must according to us the national condition, adopts the country, the collective, individual to undertake the medical insurance policy together realistically.
Second, strengthened government's responsibility. The prompt adjustment basic medical insurance“three tables of contents”, develop the community health service network vigorously, strengthens advances Shan Bing to plant the settlement, develops the management type medical service plan vigorously, takes the practical measure to expand the basic medical insurance coverage.
Third, through strengthens individual specie payment, establishes all the people health insurance, speeds up the health organizational reform and the drugs circulation structural reform, the health insurance manages measures and so on hospital, the guard medical service demand side and the supplier moral hazard.
Fourth, the desalination and cancels basic medical insurance individual account finally.
Fifth, prevention fund deficit risk. Strengthens the medical insurance fund operational aspect the analysis and the predict that the standard fund financial management system, enhances the overall plan level, enhances the medical insurance fund to draft giving rate, strengthens the basic insurance fund control of expenditure, establishes the basic medical insurance reserve gold system.
Sixth, practices the basic medical insurance lowest payment age limit system, the payment age limit and the medical treatment suspension hook.
一是个人费用负担重。实施几年来,个人所负担的医疗费用占医疗总费用的比例平均为30%,整体上有一定幅度的上涨,尤其是国家机关公务员及原来经济效益较好的企、事业单位人员更是感觉医疗保险待遇有明显下降。
二是医疗保险“扩面难”。一部分经济效益好、完全具备缴费能力的单位不愿参保,而又有一部分经济效益差、不具备缴费能力的单位不能参保。
三是存在道德风险。医疗供应方的道德风险和需求方的道德风险,导致了医疗保险基金尤其是统筹基金发生一定程度的流失。
四是基本医疗保险个人帐户效率低下。个人账户化解医疗费用风险的能力弱,管理成本高,面临贬值风险。
五是缴费年限与医疗待遇尚未挂钩。不管个人缴纳医疗保险费的多少、缴费年限的长短,享受无差别的医疗保险待遇。
六是未实行基本医疗保险最低缴费年限,退休人员享受基本医疗保险待遇与单位缴费情况挂钩。退休人员因原单位缴费不及时或无力缴费而享受不到正常的医疗待遇。完善潍坊市市级基本医疗保险制度的对策:
一是要确立全新的基本医疗保险理念。基本医疗保险的水平要与我国社会主义初级阶段的生产力发展水平相适应。现阶段就要根据我们的国情,实事求是地采取国家、集体、个人共同承担医疗保险的政策。
二是强化政府的职责。及时调整基本医疗保险“三个目录”,大力发展社区卫生服务网络,加强推进单病种结算,大力发展管理式医疗计划,采取切实措施扩大基本医疗保险覆盖面。
三是通过加强个人现金支付,建立全民健康保险,加快医疗卫生体制改革和药品流通体制改革,医保办医院等措施,防范医疗需求方和供应方的道德风险。
四是淡化并最终取消基本医疗保险个人帐户。
五是预防基金赤字风险。加强医疗保险基金运行情况的分析和预测,规范基金财务管理制度,提高统筹层次,提高医疗保险基金征缴率,加强基本保险基金支出管理,建立基本医疗保险后备金制度。
六是实行基本医疗保险最低缴费年限制度,缴费年限与医疗待遇挂钩。
In the many risks facing humanity, the disease risk serious harm, covers a wide range of complex and diverse, is directly related to basic human survival interests of the special risks. At the same time, as modern increase in the complexity of the disease, human health, the concept of change, as well as medical technology continues to progress, the rapid expansion of health care costs, making the basic medical insurance has become a world problem. The Weifang cities staff basic medical insurance system implementation time is not long, as well as basic medical insurance work's complexity, therefore present had various problems in the basic medical insurance aspect.
First, the heavy burden of personal cost. Implemented over the past few years, the personal burden of medical expenses for the proportion of the total medical costs an average of 30 percent, the overall rate of increase to a certain extent, especially the civil service and state organs, the better the original economic enterprises, institutions, the medical staff is feeling insurance benefits have decreased significantly.
Second, medical insurance "extended surface difficult." Part of good economic returns, complete with the ability to pay to unit holders, and they have the economic part of poor, and do not have the ability to pay can not be insured units.
Third, the existence of moral hazard. Medical supply-side and demand-side moral risks of moral hazard, leading to a health insurance fund is to co-ordinate fund especially in a certain degree of wastage.
Fourth, the basic medical insurance personal accounts inefficient.
Individual accounts defuse the risk of medical costs, low management costs are high, facing the devaluation risk.
Fifth, the payment age limit and the medical treatment not yet link up. No matter individual payment medical service insurance premium's how many, the payment age limit's length, enjoys the non-difference the medical insurance treatment.
Sixth, it is the failure to implement the basic medical insurance payment minimum age, retired workers enjoy basic medical insurance benefits and the payment of premiums linked units. Retirees do not pay for the original unit or inability to timely payment and could not enjoy a normal medical treatment. Weifang City municipal improve the basic medical insurance system responses:
First, must establish the brand-new basic medical insurance idea. The basic medical insurance's level must adapt with our country socialism initial stage productive forces level of development. The present stage must according to us the national condition, adopts the country, the collective, individual to undertake the medical insurance policy together realistically.
Second, strengthened government's responsibility. The prompt adjustment basic medical insurance“three tables of contents”, develop the community health service network vigorously, strengthens advances Shan Bing to plant the settlement, develops the management type medical service plan vigorously, takes the practical measure to expand the basic medical insurance coverage.
Third, through strengthens individual specie payment, establishes all the people health insurance, speeds up the health organizational reform and the drugs circulation structural reform, the health insurance manages measures and so on hospital, the guard medical service demand side and the supplier moral hazard.
Fourth, the desalination and cancels basic medical insurance individual account finally.
Fifth, prevention fund deficit risk. Strengthens the medical insurance fund operational aspect the analysis and the predict that the standard fund financial management system, enhances the overall plan level, enhances the medical insurance fund to draft giving rate, strengthens the basic insurance fund control of expenditure, establishes the basic medical insurance reserve gold system.
Sixth, practices the basic medical insurance lowest payment age limit system, the payment age limit and the medical treatment suspension hook.
引文
[1]国务院关于建立城镇职工基本医疗保险制度的决定.国发[1998]44号
[2]潍坊市城镇职工医疗保险制度改革指南.2001.10
[3]张晓等主编.社会医疗保险概论.中国劳动社会保障出版社.2004
[4]顾锋主编.管理学.上海人民出版社.2004
[5]陈冬红.社会保障学.西南财经大学出版社.1996
[6]干鸿勇.邵明远.徐媛等.多层次医疗保障体系的理论基础与政策框架.卫生经济研究.2003.5
[7]毛圣吕.发展补充医疗保险的形式探讨.中国卫生事业管理.2002.4
[8]刘源.浅谈医疗保险制度改革.中国卫生资源 2004.6
[9]张太海.释茂金.王红等.关于城镇弱势人群医疗保障问题的探讨.中国卫生事业管理.2003.3
[10]高歌.王艾丽等.上海市医疗保险职工自负医疗费用比例的调查分析.中国卫生事业管理.2003.9
[11]于广军.胡善联.城镇职工补充医疗保险发展策略研究.卫生经济研究.2002.7
[12]梅强.江里程.林枫等.镇江摸式的形成及其特征研究.中国卫生事业管理.2004 .3
[13]林 枫 等 .论 医 疗 保 险 和 服 务 制 度 的 可 持 续 发 展 .中 国 卫 生 经济.2004.2
[14]李良军.杨一先.陈滔等.商业医疗保险与基本医疗保险的衔接的研究.保险研究 2004.8
[15]李振军.浅谈我国医疗保险的发展趋势.保险研究.2004.2
[16] 秦 小 明 . 城 镇 职 工 基 本 医 疗 保 险 制 度 改 革 的 特 征 . 理 论 前沿.1999.12
[17]饶克勤.李青.回归分析在患者就诊行为影响因素研究中的应用.中国卫生统计.2000.9
[18]世界银行.中国卫生模式转变中的长远问题与对策.中国财政经济出版社.1998
[19]王鸿勇.国际医疗保险保险模式和改革发展比较分析.国外医学卫生经济分册.1998
[20]干延中.沈志渔.杜莹芬.医疗保险制度改革中的两江模式.中国工业经济.2000.7
[21]吴越新.建立三段通道式的医疗保险机制.石油企业管理.1999.5
[22]夏冰.朱尤庆.建立多层次医疗保险制度的设想.科技进步.2003.7
[23]杨平.我国医疗保险现状与发展.保险研究.2003.5
[24]杨树艳.公费医疗改革发展.医疗保险.1999.7
[25]颂东.法国医疗保险制度及其启示.管理世界.2005.4
[26]翟东华.莫京梁.医疗保险的财务风险评估.上海交通大学学报.1998.8
[27]郑功成.社会保障学.商务印书馆.2000
[28] 胡大洋.完善社会医疗保险制度的几点思考.中国医疗保险研究.2004.11
[29] 林毓铭.深化医疗保险改革的主要政策举措.江西财经大学学报.2001.5
[30]郭永松.马伟宁.论医疗保险中的道德风险及对策.中国医学理论.2004.2
[31] 卫生部卫生统计信息中心.2003 年全国卫生事业发展情况统计公告.2004
[32] 杨大峥.关于医疗保险制度改革的几个问题.中国劳动.2004.4
[33] 林凤.论医疗保险个人账户.中国医疗保险研究.2004.1
[34] 毛孟凯.我国医疗费用高涨的原因和对策分析.广西社会科学.2005.2
[35] 董建军.社会保险政策指南.山东人民出版社.1999
[36]王东进.医疗保险操作指南.改革出版社.1999
[2]潍坊市城镇职工医疗保险制度改革指南.2001.10
[3]张晓等主编.社会医疗保险概论.中国劳动社会保障出版社.2004
[4]顾锋主编.管理学.上海人民出版社.2004
[5]陈冬红.社会保障学.西南财经大学出版社.1996
[6]干鸿勇.邵明远.徐媛等.多层次医疗保障体系的理论基础与政策框架.卫生经济研究.2003.5
[7]毛圣吕.发展补充医疗保险的形式探讨.中国卫生事业管理.2002.4
[8]刘源.浅谈医疗保险制度改革.中国卫生资源 2004.6
[9]张太海.释茂金.王红等.关于城镇弱势人群医疗保障问题的探讨.中国卫生事业管理.2003.3
[10]高歌.王艾丽等.上海市医疗保险职工自负医疗费用比例的调查分析.中国卫生事业管理.2003.9
[11]于广军.胡善联.城镇职工补充医疗保险发展策略研究.卫生经济研究.2002.7
[12]梅强.江里程.林枫等.镇江摸式的形成及其特征研究.中国卫生事业管理.2004 .3
[13]林 枫 等 .论 医 疗 保 险 和 服 务 制 度 的 可 持 续 发 展 .中 国 卫 生 经济.2004.2
[14]李良军.杨一先.陈滔等.商业医疗保险与基本医疗保险的衔接的研究.保险研究 2004.8
[15]李振军.浅谈我国医疗保险的发展趋势.保险研究.2004.2
[16] 秦 小 明 . 城 镇 职 工 基 本 医 疗 保 险 制 度 改 革 的 特 征 . 理 论 前沿.1999.12
[17]饶克勤.李青.回归分析在患者就诊行为影响因素研究中的应用.中国卫生统计.2000.9
[18]世界银行.中国卫生模式转变中的长远问题与对策.中国财政经济出版社.1998
[19]王鸿勇.国际医疗保险保险模式和改革发展比较分析.国外医学卫生经济分册.1998
[20]干延中.沈志渔.杜莹芬.医疗保险制度改革中的两江模式.中国工业经济.2000.7
[21]吴越新.建立三段通道式的医疗保险机制.石油企业管理.1999.5
[22]夏冰.朱尤庆.建立多层次医疗保险制度的设想.科技进步.2003.7
[23]杨平.我国医疗保险现状与发展.保险研究.2003.5
[24]杨树艳.公费医疗改革发展.医疗保险.1999.7
[25]颂东.法国医疗保险制度及其启示.管理世界.2005.4
[26]翟东华.莫京梁.医疗保险的财务风险评估.上海交通大学学报.1998.8
[27]郑功成.社会保障学.商务印书馆.2000
[28] 胡大洋.完善社会医疗保险制度的几点思考.中国医疗保险研究.2004.11
[29] 林毓铭.深化医疗保险改革的主要政策举措.江西财经大学学报.2001.5
[30]郭永松.马伟宁.论医疗保险中的道德风险及对策.中国医学理论.2004.2
[31] 卫生部卫生统计信息中心.2003 年全国卫生事业发展情况统计公告.2004
[32] 杨大峥.关于医疗保险制度改革的几个问题.中国劳动.2004.4
[33] 林凤.论医疗保险个人账户.中国医疗保险研究.2004.1
[34] 毛孟凯.我国医疗费用高涨的原因和对策分析.广西社会科学.2005.2
[35] 董建军.社会保险政策指南.山东人民出版社.1999
[36]王东进.医疗保险操作指南.改革出版社.1999
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