【作者】 林敏；

【导师】 赵俊；

【作者基本信息】 南京医科大学 ， 社会医学与卫生事业管理， 2010， 硕士

【摘要】 研究目的:本文从南京市社会医疗保险道德风险的现状入手,通过典型案例和数据多角度、全方位地分析南京市社会医疗保险领域道德风险的种种表现和特点,并揭示道德风险的产生原因,从监督机制和激励机制两个方面对南京市现行的控制社会医疗保险道德风险的举措进行分析和评价,在此基础上从医疗保险管理者的角度提出进一步完善道德风险控制策略的建议。研究方法:本文主要采用文献分析、案例分析和专家访谈的方法,研究类型属于解释性研究。文献分析:查阅国内外有关医疗保险道德风险方面的文献,理解道德风险的相关概念,了解道德风险的研究现状,为本研究提供理论基础。案例分析:医疗保险道德风险的分类及表现。将医疗保险道德风险分为供方道德风险和需方道德风险,以案例的方式分别对各类欺诈行为进行描述。专家访谈:选择医疗保险专家、市医保管理部门相关科室负责人、南京市相关定点医疗机构医保办公室负责人就南京市医疗保险道德风险产生的具体原因以及如何完善控制机制,开专家座谈会,听取专家的意见和建议。研究结果与分析:由于社会医疗保险制度本身的缺陷和我国医药卫生体制的不完善滋生了道德风险。从收集的资料中分析出南京市目前涉及金额比较大的几种违规现象,重点控制住这几种现象就可以控制住绝大多数违规行为。板块式统账结合模式下管理集中方便,主抓住院即可,有效设计定点医院约束机制是解决医疗保险道德风险问题的关键。南京市2006年实行的新结算办法是一种混合式预付制费用支付方式,预付制作为一种激励机制,在约束道德风险控制医疗费用方面起到积极的作用。讨论:在新医药卫生体制改革逐步和全面推进的前提下,通过科学合理的制度设计,整体推进,才可以有效地规避供需双方的道德风险。针对医疗服务供给方,推进医药卫生体制改革及完善相关控制措施;针对医疗服务需求方,要进一步完善社会医疗保险制度设计;针对医疗保险机构,提高医疗保险经办能力。更多还原

【Abstract】 Objectives: From the situation of Nanjing social medical insurance moral hazard, by introducing typical cases and data analysis, multi-analysis the personal characteristics and behaves of Nanjing social medical insurance moral hazard , and reveal the reasons of moral hazard .From monitoring mechanisms and motivational mechanism these two aspects to analyze and evaluate the existing control measures of the Nanjing social insurance moral hazard, based on medical insurance managers from the angle put forward to further improvement of the moral hazard control strategy proposal.Method:This article mainly analyses the documents and case studies and experts interviews, the type is belong to explanatory study. Documents for the analysis: refer to the documents of social insurance moral hazard home and abroad, and understand related concepts of the moral hazard and understand the study status quo of moral hazard, to offer a theoretical basis. Cases study :Medical insurance moral hazard of classification and performance, moral hazard in social health insurance is divided into two parts: the moral hazard of health service supplier (supplier moral hazard), and that of health service demander (demander moral hazard), in cases by moral hazard of fraud in each of all description. The selection interview: medical insurance experts, the relevant department head of social medical insurance management in Nanjing city, the relevant department head of designated medical institution in charge of the office in Nanjing, social medical insurance moral hazard of the specific reasons and to improve the control mechanism and the meeting is to receive expert advice and suggestions.Results and analysis: The social insurance system is flawed and our medical and health care system does not improve breeding ground for the moral hazard. From the collection of data from Nanjing to the present analysis of large amount of several contrary, the control of this phenomenon can control the most becoming. Channel payment model, Centralized management, will take charge of hospital and efficient design and restraining mechanism for regular hospital for medical insurance is the moral hazard of the problem. The new settlement method which implemented in 2006 years is a mixing advance payment in advance of the cost, this payment make as an incentive mechanism, it played an active role in restricting of moral hazard and controlling medical fees.Discussion:On medical insurance system reform and medical and health care system and the drug distribution system and reform in coordination with the premise, through scientific and system design, the overall design, can effectively avoid the moral hazard of health service supplier (supplier moral hazard), and that of health service demander; For health service supplier, the promotion of the health system reform and improve the control measures;For health service demander to further improve the social insurance system design; for medical insurance sector and increase insurance handling capacity更多还原