摘要
社会医疗保险必须控制医疗费用支付的风险,中国城镇职工基本医疗保险采取全国统一的模式,区分参保人住院和门诊费用,分别建立统筹账户和个人账户进行支付。在此支付方式下,为了防止个人门诊费用负担过重,该制度还设计了统筹账户转移部分费用到人账户政策和门诊部分超额费用统筹报销的模式。本文以B市2007年到2012年数据为基础,提出了按年龄分布的支付风险因子的理念和计算,发现伴随着近年来人口结构的变化,现有的基金支付方式使得医疗保险"基金支付风险"不同于"医疗费用风险"的按不同年龄的分布,不同年龄段医疗费用结合现有的支付方式使得相对年轻的"老龄"群体"医保基金支付风险"的增加,而这种"扭曲"和改变会随着中国人口老龄化整体趋势会严重影响医保基金支付的整体风险,本文根据支付方式与参保人年龄结构综合作用的风险的分布进行了分析并给出相应的政策建议。
The Statutory Health Insurance must control the payment risk. The statutory health insurance to the urban employees in China has adopted the same payment measures across China and that is the division of inpatient and outpatient expenses. The individual accounts（ IA） and social pooling（ SP） are set up in order to pay the outpatient and inpatient expenses separately. In order to lower the individual patients ’ burden of outpatient expense,there are the measures that part of the social pooling funds will go to the IAs and the extra amounts of outpatients’ expense will be covered by the SP. Based on the data and reality of B city,it is found in this paper that in the process of demographic change,due to the payment measures,the allocation of SHI funds payment risk indicator and the the health care expense indicator among different age groups are changed. Some age groups of relatively younger elders’ risk indicator is the biggest not the eldest age groups. This kind of change may lead to the increase of the whole SHI funds risk in the demographic change. The allocation of the SHI funds payment risk indicator are calculated and analyzed in this paper,and some policy advice are suggested in this paper to face the change of risk allocation among different age groups.
出处
《社会保障研究》
CSSCI
2016年第1期47-54,共8页
Social Security Studies
关键词
医疗保险
支付政策
人口结构变化
风险因子
statutory health insurance
demographic change
payment measures
risk indicators
