医疗保险中欺诈问题的博弈分析

从现行的医疗保险欺诈行为的具体表现为切入点,对医疗保险相关利益集团进行博弈分析,分析医疗保险管理机构同参保人、医保定点医院间的利益关系,探讨了医疗保险管理机构如何通过有效手段处理医疗保险欺诈行为。     

医保管理工作中精细化管理的应用

随着我国医疗体系的不断完善,医疗保险的范围也越来越广,如果想要让人们能够更好地享受医疗保险所带来的好处,就应该积极应用精细化管理,有效提升医疗保险工作水平。医院应制定相应完善的制度,提升医保管理工作效率,推动医院向更好的方向发展。该文阐述医保管理工作中精细化管理的重要性,说明为何要在医保管理工作中应用精细化管理的原因,最后提出医保管理工作中精细化管理应用措施。     

浅析我国商业健康保险对社会医疗保险的补充作用

社会医疗保险和商业健康保险共同构成了我国的医疗保障体系,其中社会医疗保险是基础,商业健康保险是必要补充。目前,我国商业健康保险业务量小,覆盖率低,对医疗费用的分担少,因此其对社会医疗保险补充作用的发挥程度较低,这是由医疗保险所针对风险的特殊性所决定的。为了充分发挥商业健康保险对社会医疗保险的补充作用,必须加强政商合作,实行专业化经营,加强人才培养,构建有吸引力的医保合作框架,针对特殊风险进行业务创新等。     

我国社会医疗保险制度城乡一体化的路径探析

医疗保险是社会保障体系中涉及面最广、险种最多和涉及时间最长的险种之一,伴随着改革开放的推进,我国的社会医疗保险制度基本建立,但同时也暴露出不少的弊端。为了缓解现行社会医疗保险制度运行中凸显的矛盾,不同地区都在积极地尝试对社会医疗保险制度进行改革。从4种不同的路径对＂渐进式＂社会医疗保险制度城乡一体化之路进行探析,以寻求一条适合中国国情的社会医疗保险制度。     

我国社会医疗保险“逆向转移”现象研究

社会医疗保险是保证社会成员公平享有基本医疗服务,促进全民健康水平提高的重要工具,但部分微观制度设计的不当,造成社会医疗保险在收入再分配上呈现从低收入者向高收入者转移的"逆向转移"情况,是一种效率和公平的双损失。文章从微观制度设计角度分析我国社会医疗保险出现收入再分配"逆向转移"现象的原因,提出通过在医疗保险费用征收和医疗保险待遇给付两个环节对相应微观制度设计进行调整,并结合其他国家经验,提出扭转这种收入再分配上的"逆向转移"现象的建议。     

Health insurance and child mortality in Costa Rica

This study uses a natural experiment approach to evaluate the effect of health insurance on infant and child mortality. In the 1970s Costa Rica adopted national health insurance, which expanded children's insurance coverage from 42 percent in 1973 to 73 percent by 1984. Aggregate infant and child mortality rates dropped rapidly during this period, but this trend had begun prior to the insurance expansion, and may be related to other changes during this period. We use county-level vital statistics and census data to isolate the causal insurance effect on mortality using county fixed effects models. We find that insurance increases are strongly related to mortality decreases at the county level before controlling for other time-varying factors. However, after controlling for changes in other correlated maternal, household, and community characteristics, fixed effects models indicate that the insurance expansion could have explained only a small portion of the mortality change. These results question the proposition that health insurance can lead to large improvements in infant and child mortality, and that expanding insurance to the poor can substantially narrow socioeconomic differentials in mortality.     

从分散到统一:荷兰基本医疗保险制度改革对我国的启示

2006年1月1日,荷兰基本医疗保险制度进行了大刀阔斧地改革,将3个分散计划(疾病基金保险计划、私人商业医疗保险和公务员医疗保险计划)合并为一个统一的基本医疗保险制度。荷兰改革的根源在于原有医疗保险制度存在分散化带来的不公平性、垄断带来的效率低下等诸多弊端。我国目前的医疗卫生状况与荷兰改革前非常相似,基本医疗保险制度也针对不同人群实施了不同计划(城镇职工基本医疗保险、城镇居民基本医疗保险、公费医疗保险和新型农村合作医疗保险)。荷兰的改革经验对我国基本医疗保险制度改革和医疗卫生体制的构筑具有一定的启示和借鉴意义。     

基于熵权TOPSIS法和RSR法对不同医疗保险下的老年人健康状况评价

目的 运用熵权TOPSIS（Entropy weight TOPSIS）法与秩和比（RSR）法综合评价我国2018年四种医保下老年人健康状况,为决策者制定相关政策提供参考依据。方法 以中国老年健康影响因素跟踪调查（CLHLS)中的5种健康指标(自评健康率、健康改善率、他评健康率、ADL完好率、慢性病患病率）为基础,使用 Excel 和SPSS 22.0 软件,采取熵权TOPSIS和RSR相结合的方法对我国2018年各医保类型下老年人健康状况进行综合评价并分档。结果 不同医保下居民健康状况存在差异。熵权TOPSIS法和RSR法评价结果一致,排序均为商业医疗保险、公费医疗、新型农村合作医疗保险、城镇职工/居民医疗保险。RSR法分档结果为三档,商业医疗保险被评为“优秀”（RSRi＞0.679）,公费医疗、新型农村合作医疗保险、城镇职工/居民医疗保险均被评为“良好”（0.504≤RSRi＜0.679）,无被评为“一般”（RSRi＜0.504）。且方差分析显示各档差异具有统计学意义（F=51.766,P＜0.001）。讨论 增强对医疗保险不公平性的重视;建立全民统一的基本医疗保险框架;加强对弱势群体的保护。     

“军卫一号”住院医疗保险管理系统的设计

目的：设计开发一套符合当地医疗保险政策要求和满足医院对医疗保险管理工作需求的医疗保险管理系统。方法：通过对当地医保政策和医院对医保管理需求的分析,结合医院对医疗保险患者的流程控制,在“军卫一号”信息系统的基础上,采用C／S模式,基于VB．NET技术,利用Visual Basic 2005开发工具,编写住院医疗保险管理系统的功能代码。结果：该系统的成功研制,使得医院管理人员能对住院医保患者实行全程管理和动态跟踪．实现了医保管理全程微机化操作。结论：该系统采用模块化设计,可扩展性强,安装操作简单,提高了医保工作效率和管理能力．具有较高的实用价储．     

江夏区城乡医保整合后试点居民参保意愿及影响因素分析

目的了解武汉市江夏区城乡医保整合后试点居民参保意愿的真实情况及主要影响因素,为武汉市完善城乡医保整合政策提供依据。方法于2018年6月,运用分层随机抽样方法,抽取武汉市江夏区3个街道和6个乡镇的城乡居民共356人进行问卷调查,对可能影响居民参保意愿的因素进行单因素χ^2分析和多因素Logistic回归分析。结果共调查356人,其中258人(72.47%)表示仍愿意参加城乡医保,98人(27.53%)表示不愿意继续参加;对当前制度表示满意的有317人(89.04%),不满意的有39人(10.96%);对当前制度了解的有230人(64.61%),表示不了解的有126人(35.39%);Logistic回归分析结果显示,农村居民(OR=0.484)、对医保报销后费用负担评价较认可(OR=2.009)和报销便捷度较方便(OR=2.379)是影响城乡居民参保意愿的主要因素(P<0.05)。结论江夏区城乡医保整合后居民参保意愿较高,但医保制度的设计需关注居民医保费用负担与医保报销状况,并加强宣传力度,提高城乡居民对医保整合的认知。     

杭州市农民工医疗保障现况调查

目的 了解当前杭州市农民工参加医疗保险的状况,为建立健全农民工的医疗保障制度提供依据.方法 采用问卷调查方式,对杭州市930位外来农民工就对医疗保险的认识、参加社会保险情况、未参加医疗保险的原因等内容进行了调查和访谈.结果 有44.1%的人认为医疗保险最重要;49.0%的农民工未参加任何保险,35.2%的农民工参加了养老保险,31.6%的人参加了医疗保险.参保率低的原因有多种.结论 要加强医疗保险政策宣传力度,积极推进社会保障立法,实现法制化管理.要适应农民工群体流动性、多样性的特点,实行以大病统筹为主体的多层次、多险种的医疗保障,实现参保方式的灵活转换.     

基于大数据的基本医疗保险参保人欺诈风险评估

目的:构造基本医疗保险参保人欺诈风险预测模型,发现欺诈行为的主要特征,进而建立风险评估指标体系,以期为医保基金智能监管提供决策支持。方法:利用183万多条我国基本医疗保险诊疗历史记录的大规模真实数据,应用XGBoost算法和EasyEnsemble方法构造基本医疗保险参保人欺诈风险评估集成模型。在此基础上,利用特征重要度计算进一步识别和量化欺诈行为人的潜在特征以构造欺诈风险评估指标体系。结果:模型预测结果的准确性为83%;阳性与阴性预测值的加权平均值为95%;参保人欺诈的可能性能够被正确评估的概率为85%;其中,实际产生欺诈行为的所有参保人中,有82%的人员能通过本模型正确识别;各项费用发生金额、各阶段费用发生金额以及各类项目的数量等是区分欺诈与正常参保人的重要指标。结论:基于XGBoost集成模型构建的基本医疗保险参保人欺作风险评估指标体系能够有效地用于识别潜在欺诈人员。建立健全的风险评估指标体系并开发基于医保大数据的智能化监控系统,对于提高医保管理服务水平,保障医保基金安全以及维护社会医保的公平性有重要作用。     

某市医疗保险监督管理工作的难点及对策思考

如何有效使用医疗保险基金和保障参保人的合理权益是医疗保险监督管理工作的重要责任。文章阐述了大连市目前的运行现状、在医疗保险监督管理过程中存在的难点,并从完善政策、完善流程、提高定点医疗机构自身管理、扩大宣传力度等6个方面阐述了解决难点的对策。     

新疆某二级医院住院医保定额管理模式探讨

目的：研究定点医院如何科学、合理地用足用好各社保局分配的住院医保定额。方法通过自身前后对比法和德尔菲法,对新疆某二级甲等综合性医院2011—2014年给各临床科室二次分配和实际使用的住院医疗保险基金的额度进行对比,对医院住院医保定额管理与控制进行相关分析和评价。结果定点医院通过对住院医保定额的二次分配,13%的临床科室超出核定的额度,87%的临床科室完成的额度控制在合理的区间。结论在定点医院推广住院医保定额管理模式有效控制了住院医疗保险定额的超支比例,提高了医保基金的总额预算和总控成效,避免了定点医院因住院医保定额超支导致医疗保险基金分担的经济风险。     

An analysis of private health insurance purchasing decisions with national health insurance in Taiwan

The Taiwanese health insurance industry is just over 30 years old. Originally private and domestic, the industry underwent substantial institutional changes when it opened to foreign competition between 1987 and 1994 and when the Taiwanese government established national health insurance (NHI) coverage in 1995. Congruent with these changes, rapid growth occurred in the Taiwanese demand for private health insurance. In order to better understand the recent performance of the Taiwanese health insurance industry, the structure of the NHI system is described and then household decisions to purchase private health insurance are analyzed using a two-part (hurdle) model on 1998 Survey of Family Income and Expenditure data. Logistic and OLS regressions are used to examine the factors influencing the probability and amount of private health insurance purchased. Generally, factors affecting the probability of having insurance also influence the amount of insurance coverage purchased. Higher income and education levels are associated with increased probabilities and larger quantities of private insurance purchases. Married females, the employed, and household heads working in state-run enterprises are more likely to purchase private insurance than their counterparts. The probability of private insurance purchases varies by region, with northern Taiwanese households having higher odds of owning private insurance than non-northern households. Compared to those in rural villages, households in cities and towns are more likely to have private insurance. The likelihood of private insurance purchase also tends to rise with advancing age and larger family sizes. In addition, one important implication in the private health insurance market is highlighted. There is no complementarity between the public and private systems.     

基于某医院医保住诊人次及费用的调查分析

目的基于某医院医保住诊人次及费用的调查,探索医保基金管理的有效途径。方法抽调某医院医保管理中心2010至2012年度报表,统计住诊人次及费用,采用Logistic线性回归模型进行分析,比较医保住诊人次及费用的变化和趋势。结果2011医保年度医保住诊人次增幅39.6%,2012医保年度医保住诊人次增幅35.6%,年度增幅比较差异具有统计学意义(P<0.05),虽然增幅有所下降,但仍保持较高的增长幅度;2011医保住诊费用增幅50.9%,2012医保住诊费用增幅29.1%,年度增幅比较差异具有统计学意义(P<0.05),但其年增幅逐年有所下降,且下降幅度较大。结论医保基金管理存在的问题具有结构刚性的特点,树立共同管理医保基金的意识,提高基层医疗水平,实现医保管理信息化,引导老年居民合理使用医保基金,有利于防止滥用医保基金、浪费医疗资源。     

Reforming health insurance in Argentina and Chile

The paper examines the recent reforms of health insurance in Chile and Argentina. These partially replace social health insurance with individual insurance administered through the private sector. In Chile, reforms in the early 1980s allowed private health insurance funds to compete for affiliates with the social health insurance system. In Argentina, reforms in the 1990s aim to open up the union-administered social insurance system to competition both internally and from private insurers. The paper outlines the specific articulation of social and individual health insurance produced by these reforms, and discusses the implications for health insurance coverage, inequalities in access to healthcare, and health expenditures.     

Insured without moral hazard in the health care reform of china

Public insurance possibly increases the use of health care because of the insured person's interest in maximizing benefits without incurring out-of-pocket costs. A newly reformed public insurance scheme in China that builds on personal responsibility is thus likely to provide insurance without causing moral hazard. This possibility is the focus of this study, which surveyed 303 employees in a large city in China. The results show that the coverage and use of the public insurance scheme did not show a significant positive effect on the average employee's frequency of physician consultation. In contrast, the employee who endorsed public responsibility for health care visited physicians more frequently in response to some insurance factors. On balance, public insurance did not tempt the average employee to consult physicians frequently, presumably due to personal responsibility requirements in the insurance scheme.     

Health insurance and health services utilization in Ireland

The numbers buying private health insurance in Ireland have continued to grow, despite a broadening in entitlement to public care. About 40% of the population now have insurance, although everyone has entitlement to public hospital care. In this paper, we examine in detail the growth in insurance coverage and the factors underlying the demand for insurance. Attitudinal responses reveal the importance of perceptions about waiting times for public care, as well as some concerns about the quality of that care. Individual characteristics, such as education, age, gender, marital status, family composition and income all influence the probability of purchasing private insurance. We also examine the relationship between insurance and utilization of hospital in-patient services. The positive effect of private insurance appears less than that of entitlement to full free health care from the state, although the latter is means-tested, and may partly represent health status.     

我国城镇商业健康保险区域发展非均衡及影响因素分析

选取2007—2016年我国东中西部地区的城镇商业健康保险收入和支出数据,利用保险密度、保险深度和Theil指数分析我国城镇商业健康保险的发展速度和非均衡程度,结果表明:三个地区城镇商业健康保险都处于增长状态,且发展速度由东向西依次递减;东部地区城镇商业健康保险非均衡程度最大,其次是西部地区,中部地区最小。利用灰色关联分析法从风险认知程度、人均地区生产总值、收入和社会保险支出等方面分别对东中西部的商业健康保险发展的影响因素进行分析,结果发现,收入和人均地区生产总值对三地区的影响程度都很大,社会保险支出对东部地区的影响比风险认知度大,而风险认知程度则对中西部地区的影响较东部地区明显。最后,针对分析结果对城镇商业健康保险的发展提出几点建议。