【作者】 邱月；

【导师】 施国庆；

【作者基本信息】 河海大学 ， 技术经济及管理， 2005， 硕士

【摘要】 医疗保险市场的风险控制是医疗保险领域的重要问题之一。商业医疗保险市场的主体有三个：投保人、医疗服务机构、商业保险公司，不同的市场主体面对的风险是不同的。在本文中探讨了商业保险公司面对的风险以及如何对这些风险进行控制。 分析了商业医疗保险市场的供需特点和供需均衡等。商业医疗保险市场包括两个市场，医疗市场和商业医疗保险市场。运用经济学的方法对两个市场的供需均衡进行分析可以得出两个市场是失衡的，失衡的原因是在商业医疗保险市场中存在很多风险。 分别从投保人和医疗供方两个角度探讨了商业保险公司面对的风险。运用委托-代理理论分析了投保人与医疗供方之间的关系，得出二者之间道德风险的产生与医疗费用的支付方式有很大的关系。运用博弈理论分析了商业保险公司和医疗供方之间的关系。 商业保险公司要从投保人和医疗供方两个方面进行风险控制。对投保人要从条款设计、核保、理赔、保健等几个方面控制风险。通过数学模型对投保人的最优共担比例进行了分析。对医疗供方要从医疗服务的过程、医疗费用支付的方式、医院与保险公司的合作几个方面来控制风险。运用数学模型对预付制的激励问题进行了分析。更多还原

【Abstract】 How to control the risks of the commercial medical insurance market is one of the important promblems in the field of medical insurance. There are three bodies in the commercial medical insurance market : policy holders, medical service providers, commercial insurance companies . Different market bodies face different risks . In the article, the risks the commercial insurance companies face and how to control the risks will be studied.In the article ,the characteristics of the supply and demand in commercial medical insurance market are studied. At the same time , the balance between the supply and demand in the commercial medical insurance is also studied. The commercial medical insurance market includes the medical market and the insurance market. By analyzing the supply and demand of the both market in economic methods, we can get the conclusion that unbalance of the both market result from the risks existing in the both market.The risks commercial insurance companys face are discussed in the angles of policy holders and medical service providers. The relationship between policy holders and commercial insurance companys is studied in the theory of "Entrust-Deputize" .The ideal that the moral risks between policy holders and commercial insurance companys are connected with the manner of payment is concluded. The relationship between commercial insurance companys and medical service providers is studied in the the "GameTheory".To the commercial insurance companys, the risks should be controlled from both policy holders and medical service providers. To the policy holders, the risks will be controlled from insurance clause , insurance checkage, insurance indemnity , health protection. The best proportion of medical expenses that the policy holders have to pay is studied in the article. To the medical service providers, the risks will be controlled from the course of medical service , the method of payment , the cooperation between medical service providers and commercial insurance companys. The promoting mechanism of payment ahead of time is studied by the mathematics model.更多还原