图书
In the primary stage of socialism, where social productive forces are not developed enough and material wealth is not rich enough, how to provide adequate protection to the people as much as possible while raising funds fairly and reasonably, and solve the contradiction between health financing and treatment needs, is the core issue of improving the construction of the social medical insurance system with Chinese characteristics. The correlation mechanism between financing and treatment discussed in this book mainly analyzes the financial balance mechanism of the social medical insurance system fund from the macro level. From the perspective of the mechanism of financing and treatment, the financial year balance mechanism of the social medical insurance fund has two basic modes: revenue and expenditure and expenditure. Revenue and expenditure are determined according to the income of funds that can be raised, and the characteristic is that budgeting does not generate deficits, which is conducive to controlling expenditure costs. Expenditure is the opposite of expenditure and expenditure is based on the basic principle of raising the required funds according to the scale of expenditure needs. For the social medical insurance system, in theory, the premium approval is based on the results of risk assessment and prediction, and "income is determined by expenditure" is the inherent law of the insurance system. However, in practice, China's basic medical insurance system for urban workers claims that "revenue and expenditure" are the basic principle. What is the difference between the two break-even principles? Why does China's basic medical insurance system for urban workers claim that "revenue and expenditure" are the basic principle? What is the practical effect? Is it possible and necessary for China's social health insurance to shift to a "income-based" financial balance model? On the surface, these problems seem to be irrelevant, but if they follow different paths to practice, they will produce different practical effects, and some administrative directions are even very different, which is not only related to two different institutional concepts, financing concepts and management service concepts, but also related to the welfare cost of the construction of China's social medical insurance system, and more related to the determination of the treatment level of the social medical insurance system and the long-term sustainable development of the system, which is actually the core issue of the construction of the social medical insurance system. In order to theoretically clarify the basic connotation, origin and specific measurement methods of the two social medical insurance financial balance principles of "revenue to determine expenditure" and "expenditure to determine income", compare and analyze the similarities and differences between the two, clarify the relevant basic concepts, and better guide the preparation of social medical insurance financial budget, this book sorts out the basic concepts, institutional characteristics and main functions of China's social medical system, and studies and analyzes the similarities and differences between the financial balance methods of revenue and expenditure from the comparative perspective of combining theory and practice. From the perspective of income and expenditure linkage, a model of financing and treatment linkage mechanism suitable for China's social medical insurance policy environment is constructed, so as to analyze and reveal the intrinsic law of the financial balance of China's social medical insurance fund. Through the research of this book, it is found that the financing and treatment of social medical insurance are two aspects of the same thing, and the two are embedded in the construction of the system, supporting each other, interrelated, and indispensable. If you separate the two and follow different paths, it may have very different effects. The so-called social medical insurance financing and treatment linkage mechanism is essentially the result of the comprehensive effect of the system covering the population structure and its health status, medical consumption service prices and treatment guarantee levels, and is the interactive relationship between the participating factors and the other. In the model of the linkage mechanism between financing and treatment, the contribution base is inversely proportional to the rate, and the population burden coefficient, hospitalization rate, the ratio of the average cost to the average salary, and the reimbursement ratio are directly proportional to the rate. Determining income by expenditure is the essential law of the financial balance of social medical insurance, and there are bound to be many problems in the policy practice of determining expenditure by revenue. Based on the association model constructed in this book, three levels of quantitative analysis and research are mainly carried out: first, the mathematical model of the financing and treatment association mechanism is constructed, and the quantitative relationship between the endogenous elements of the social medical insurance financing and treatment association mechanism is verified and revealed in the simulated real policy environment. For example, under the given assumption, for every 1 percentage point increase in hospitalization rate, the rate needs to increase by 0.29%; For every 1 percentage point increase in the average hospitalization cost compared with the average salary, the corresponding rate needs to be increased by 0.2%; For every 1 percentage point increase in the population burden coefficient, the rate needs to be increased by 0.14%; If the average hospitalization expense reimbursement ratio increases by 1 percentage point, the required rate will increase by 0.07%. Second, based on the constructed mathematical model, substitute statistical experience data, and evaluate the practical effect of policy practice on China's financial balance model of "revenue and expenditure". After empirical analysis, it is found that: in practice, China's urban employee medical insurance system promotes the basic principle of "revenue and expenditure", not only has a high excess burden and rate distortion (in the 11 years from 2005 to 2015 in Province G, the basic medical insurance system for urban employees collected a cumulative excess burden of about 34.29%, an average annual rate distortion of about 2.09%, and the distortion coefficient of the rate accounted for about 23.73% of the nominal rate), and behind the seemingly relatively stable rate, In fact, there is a hidden mystery in relying on the fee base to cope with the increase in spending; Behind the basically stable price of medical services, there is a rising hospitalization rate; The payment period policy is simple and extensive, and the setting is too low; Under the guiding principle of determining expenditure by revenue, in fact, there are problems such as blind and frequent adjustment and improvement of medical insurance treatment, resulting in overwhelmed medical insurance funds. The third is to apply the basic principles of the association between financing and treatment, and carry out case application research in combination with the relevant policy requirements of the current national "13th Five-Year Plan" reform to verify the feasibility, scientificity and practicality of the social medical insurance financing and treatment association mechanism constructed in this book. It can be seen from the case calculation of maternity integration into medical insurance that the so-called fairness of financing mainly lies in the equal payment obligation among the same contributors; The responsibility of the government lies in providing subsidies to those who cannot afford to pay. From the perspective of the relationship between financing and treatment, solving the burden of high medical expenses mainly relies on a multi-level medical security sharing mechanism. Based on theoretical research and multiple quantitative analysis research, this book argues that the current principle of "revenue and expenditure" in China's social medical insurance system does not conform to the inherent development law and basic theoretical requirements of the social medical insurance system itself, and there is also a high excess burden and distorted rate mechanism in practice. Under the thinking of single cost control, it is easy to lead to an inflated hospitalization rate; The adjustment of treatment lacks scientific basis and unified standards. Based on the analysis of long-term actuarial balance, this book also finds that the payment period policy of basic medical insurance for urban employees in China ignores its important role under the short-term annual balance mechanism, and it is urgent to further adopt scientific methods to set it uniformly. Based on the above research, this book suggests that today, with the gradual improvement of policies and regulations, the increasingly sound construction of systems, the gradual standardization of system operation, the continuous improvement of information system functions, and the increasingly developed scientific and technological means such as big data, China's social medical insurance system should comprehensively shift to the financial balance model of "income by expenditure". Specifically, we should further improve the construction of China's social medical insurance system from the aspects of scientifically defining appropriate standards for medical insurance treatment, improving the income creditworthiness system, standardizing the payment base, scientifically and uniformly setting standards for the number of years of payment, strengthening the government's responsibility for allocating funds to low-income people, and improving the synergy of the multi-level medical security system. Following the model of financing and treatment correlation mechanism constructed in this book, the internal law of the association between financing and treatment of social medical insurance can be easily operated and convenient, and its model is also the essential connotation of the construction of social medical insurance system. In addition, another major contribution of this book is that, based on the concept of life cycle actuarial balance, a scientific formula for determining the minimum payment period is designed, which is similar to the monthly table of pensions, which can be used to unify and improve the minimum payment standards of basic medical insurance for urban employees in China, which has strong policy innovation value and practical application value. Due to the limitation of ability, this book does not carry out specific discussions and detailed research on the management system, legal environment, mechanism risks and specific operational measures of the financial balance of the "income by expenditure" type social medical insurance fund. insufficient explanation of the connotation, function and significance of the constructed association mechanism model; The research methods used are also relatively simple, and these need to be further developed at a later stage. In addition, the data used in this book is mainly extracted by statistical analysis of the data of the financial insurance engineering system, although I have carefully screened it, it may inevitably be incomplete, and the relevant conclusions are only responsible for the sample. Keywords: social medical insurance, financing, treatment, correlation mechanism(AI翻译)
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