城乡居民基本医疗保险基金平衡的随机模拟研究

目的:探讨城乡居民基本医疗保险基金平衡的测算方法,为医保管理部门和研究者提供科学参考。方法:通过现场调查获得参保人群的就医参数,采用蒙特卡罗随机模拟的方法,模拟测算在不同补偿方案下基金的平衡情况。结果:参保人群的年住院率为8.76%,县内住院比例为40%,实际补偿率为52%;将乡镇卫生院、县级医院、市级医院和市外医院住院的实际补偿比分别提高到82%、75%、56%和51%时,基金使用率分别为91%、95%、99%和96%。结论:同等比例提高县级医院和市级医院的补偿比时,基金的使用率的提高相对较快,建议补偿政策继续向基层医疗机构倾斜;随机模拟技术可以为医保基金的平衡测算提供新方法。

Study on Balancing the Funds of Basic Medical Insurance System for Urban and Rural Residents Based on Stochastic Simulation

Objective: To explore a measuring method of balancing the funds of Basic Medical Insurance System for Urban and Rural Residents and to provide scientific suggestions for social medical insurance management departments and related researchers. Methods: Through the cross-sectional investigation to obtain parameters of the insured population, Monte Carlo simulation model was constructed to estimate the fund balance based on kinds of reimbursement schemes. Results: The insured population hospitalization rate was 8.76% in 2014, the proportion of hospitalization within the county was 40%, and the actual reimbursement ratio was 52%. The township hospitals, county hospitals, municipal hospitals and outside Wenzhou hospitals actual reimbursement ratio were increased to 82%, 75%, 56% and 51% respectively, the fund utilization ratio were 91%, 95%, 99% and 96% respectively. Conclusion: When the reimbursement ratio of the county hospitals and municipal hospitals was improved, the fund utilization ratio was relatively high. This study proposed reimbursement policy continues to focus on the primary health institutions. Stochastic simulation technique can provide a new method for medical insurance fund balance calculation.