整体性治理视角下贵州省职工医保基金的省级统筹研究

【作者】 张倩；

【导师】 王微；

【作者基本信息】 贵州大学 ， 公共管理， 2023， 硕士

【摘要】 提高基本医疗保险基金统筹层次,实现省级统筹是增强基金抗风险能力以及解决医疗保障领域发展不平衡、不充分的重要举措。贵州省9个统筹区对应着9种不同的政策标准,基本医疗保险基金的筹资标准、待遇水平以及相关支持系统在政策设定上存在着较大差异,政策碎片化问题较为严重。推进城镇职工基本医疗保险基金省级统筹面临着筹资标准差异大,各方利益难以协调;待遇水平差异大,各类群体难以兼顾;支持系统不统一,统筹整合难度较大;权责界定不清晰,基层道德风险增加等挑战。针对以上问题,本文基于整体性治理理论的分析框架,从协调机制、整合机制、信任机制三个维度探索贵州省城镇职工基本医疗保险基金实现省级统筹的行动路径。一是在协调机制上,采取科学测算方法设置统一筹资标准及待遇水平。筹资标准及待遇水平的协调统一是实施基本医疗保险基金统收统支省级统筹的关键,本文利用健康保险筹资模型(ILO筹资模型)中的保险成本子模型对贵州省城镇职工基本医疗保险基金省级统筹下的筹资标准进行测算,计算得出企业筹资标准为7.0%,该筹资标准符合贵州省的筹资实务,可较好实现参保人受益水平和企业缴费负担之间的平衡。在7.0%的筹资标准下,依据粗估法中的平衡系数法对拟定的35个待遇方案的适宜性待遇水平进行分析,最终得到3个最优水平待遇方案和12个次优水平待遇方案,政策调整余地较大,说明ILO筹资模型及粗估法适用于基本医疗保险基金省级统筹下筹资及待遇测算,该方法可为贵州省及其他省市制定基本医疗保险省级统筹筹资及待遇方案提供科学可靠的测算依据。二是在整合机制上,应整合基金管理及定点管理相关部门,整合经办服务及信息系统等相关信息技术,具体措施包括建立纵向层级间基金分担激励机制和基层部门基金风险应对机制;提高基层医疗质量和医疗服务水平;强化分级诊疗制度建设;制定全省统一的业务经办流程;提高基层的经办服务能力;深入探索全国医保信息平台。三是在信任机制上,在统筹主体间权责界定方面,应合理划分省市县权责,建立有效激励机制;在统筹地区间风险防范方面,应有效遏制道德风险,建立绩效考核体系。本文有助于提高城镇职工基本医疗保险基金省级统筹事业的科学性和稳健性。旨在解决制度的碎片化问题的整体性治理理论与医疗保险基金的省级统筹高度契合,将其用于研究医疗保险省级统筹领域,有助于丰富整体性治理理论的研究范围和基本医疗保险省级统筹的理论体系,对贵州省及其他相似省份解决城镇职工基本医疗保险基金省级统筹的关键问题提供实证资料、理论依据和政策参考。更多还原

【Abstract】 It is an important measure to realize the provincial pooling of medical insurance,which can enhance the anti-risk ability of the fund and solve the unbalanced and inadequate development of the medical security field.There are 9 different policy standards in the 9 pooling areas of Guizhou Province and great differences in the policies of the medical insurance fund in terms of the financing standard,treatment level and related support system,so there is a serious fragmentation of policies.There are several problems in promoting the implementation of provincial pooling of employee medical insurance funds: large differences in financing standards,difficult to coordinate the interests of all parties;The difference in treatment level makes it difficult to accommodate different groups;The support system is not unified,so the integration is difficult;The unclear definition of rights and responsibilities leads to the increase of moral hazard at the grassroots level.In view of the above problems,based on the analysis framework of holistic governance theory,this paper explores the action path of realizing provincial pooling of the basic medical insurance fund for urban employees in Guizhou province from three dimensions: coordination mechanism,integration mechanism and trust mechanism..Firstly,in the coordination mechanism,adopt the scientific calculation method to set the unified financing standard and treatment level.The unification of financing standard and treatment level is the key to the implementation of the provincial pooling of the unified collection and expenditure of medical insurance funds.This paper uses the insurance sub model of ILO financing model to calculate the appropriate financing standard under the provincial pooling of the urban employee medical insurance in Guizhou Province,and calculates that the enterprise financing standard is 7.0%.The financing standard conforms to the financing practice of Guizhou Province,and can achieve the balance between the benefit level of the insured and the burden of the enterprise.Under the financing standard of 7.0%,according to the balance coefficient of the rough estimation method,the appropriate treatment level of 35 treatment schemes was analyzed,and finally the three optimal treatment schemes and 12 sub-optimal treatment schemes were obtained,with large room for policy adjustment.The results showed that the social health insurance financing model(ILO financing model)and the rough estimation method were suitable for the financing and treatment of medical insurance funds under the provincial pooling.The method could provide a scientific and reliable basis for the calculation of the provincial pooling financing and treatment of basic medical insurance in Guizhou province and other provinces and cities.Secondly,in terms of integration mechanism,relevant departments of fund management and fixed point management should be integrated,as well as relevant information technologies of handling services and information systems.The concrete measures include the establishment of the fund sharing incentive mechanism between vertical levels and the fund risk response mechanism of grass-roots departments;Improving the quality of community-level medical care and medical services;Strengthen the construction of hierarchical diagnosis and treatment system;To formulate uniform business procedures for the whole province;Improving the service capacity of the community;We will explore the national Medical insurance information platform.Finally,in terms of trust mechanism,aiming at the definition of power and responsibility among coordinating bodies,we should reasonably divide the power and responsibility among provinces,cities and counties,and establish an effective incentive mechanism.In order to coordinate inter-regional risk prevention,moral hazard should be effectively restrained and performance appraisal system should be established.This paper is helpful to improve the science and robustness of provincial pooling of urban workers’ basic medical insurance fund.In addition,the holistic governance theory,which aims to solve the fragmentation problem of the system,is highly consistent with the provincial pooling of medical insurance funds,so its application to the study of the medical insurance provincial pooling field is conducive to enriching the research scope of the holistic governance theory and the theoretical system of the basic medical insurance provincial pooling.This paper can provide empirical data,theoretical basis and policy reference for Guizhou Province and other similar provinces to solve the key problems of provincial pooling of urban workers’ basic medical insurance fund.更多还原