贵州省职工医疗保险省级统筹的适配性待遇水平研究*

目的：提高职工医疗保险省级统筹的科学性和稳定性,为医保管理部门提供逻辑思路、实证资料和政策参考,解决省级统筹的待遇测算问题。方法：本研究以前期运用ILO保险成本模型计算得出的贵州省省级统筹筹资标准6.20%为基准, 基于2020年贵州省职工医疗保险运行报告中的数据,根据“以收定支、收支平衡”的测算原则,利用粗估测算法中的平衡系数法,分析统收统支省级统筹模式的职工医疗保险适配性待遇方案。结果：以2020年医疗费为基数计算出的6.20%的筹资水平进行统筹,政策选择下限为住院报销80.00%,门诊报销50.00%,上限为住院报销82.00%,门诊报销55.00%,可选方案为8个; 以各统筹地区单位缴费均值6.60%的筹资水平进行统筹,政策选择下限为住院报销80.00%,门诊报销55.00%,上限提高至住院报销85.00%,门诊报销58.00%;可选方案增加至12个。结论：粗估法中的平衡系数法适合运用在省级统筹待遇水平的测算和甄选工作上,且随着统筹费率的提高,政策选择余地增大,适配性待遇水平也会相应提高。该研究可为医保管理部门制定职工医保省级统筹待遇方案提供可靠的理论依据和政策参考。

A Study on the Adaptive Reimbursement Level of Provincial Pooling of Urban Employee Basic Medical Insurance in Guizhou Province

Objective: The research is helpful to improve the scientificity and robustness of the provincial pooling of medical insurance for employees, and provide logical path, empirical data and policy reference for the medical insurance management department to solve the problem of calculating the benefits of the provincial pooling. Methods: The insurance cost sub-model of the ILO model is used to calculate the funding standard of provincial-level coordination in Guizhou Province with 6.20% as the benchmark. According to estimation principle of "balance of income and expenditure", the coefficient of equilibrium method is used to analyze the scheme of employee medical insurance adaptability for the provincial coordination model of unified collection and support. Results: The funding level of 6.20% calculated as the base of medical expenses in 2020 is used for coordination, the lower limit of policy options is 80.00% for inpatient reimbursement and 50.00% for outpatient reimbursement, and the upper limit is 82.00% for inpatient reimbursement and 55.00% for outpatient reimbursement; the number of options is 8; the funding level of 6.60% of the average value of unit contribution in each coordination area is used for coordination, the lower limit of policy options is 80.00% for inpatient. The lower limit of policy options is 80.00% for inpatient reimbursement and 55.00% for outpatient reimbursement, and the upper limit is increased to 85.00% for inpatient reimbursement and 58.00% for outpatient reimbursement. Conclusion: The equilibrium coefficient method in the rough estimation method is appropriate to be applied to the selection of provincial level of benefits. It can provide a detailed and reliable theoretical basis and policy reference for the medical insurance management department to formulate the provincial-level coordinated treatment plan for employees'' medical insurance.