大病医疗保险补偿模式及补偿效果分析——以L市为例

目的:分析西部L市农村居民大病医疗保险补偿模式及补偿效果,为完善和推广科学的大病医疗保险补偿模式提出可行性建议。方法:对补偿模式进行政策分析,运用受益率、患者自付费用、实际补偿比等指标分析大病医疗保险实施效果。结果:2013年L市大病医疗保险受益率为3.2%,基金使用率为92%,不同区县基金使用率差异较大。实行大病保险后患者自付费用下降明显,该市大病医疗保险和新农合累计实际补偿比达到84.8%,其中新农合实际补偿比已达68.9%,但同时新农合基金出现赤字。结论与建议:科学设置起付线、补偿比例、补偿范围,取消封顶线,完善大病医疗保险补偿方案;采取措施减少大病医疗保险地市统筹带来的各区县之间的不公平;实现大病医疗保险补偿模式和新农合补偿模式的有效衔接。

Analyze compensation patterns and compensation effects of catastrophic disease insurance in L City

Objective: This paper designs to analyze compensation patterns and compensation effects of catastrophic disease insurance in L City, and put forward feasible suggestions to improve the compensation patterns of catastrophic disease insurance. Methods: We combined the relevant policy documents to analyze compensation patterns, and used benefit rate, OOP and The effective reimbursement rate to analyze compensation effects of catastrophic disease insurance. Results: Catastrophic disease insurance benefit rate in L city in 2013 was 3.2%; Rates of NCMS fund unilization was 92%, which diversed from county to county. Patients' OOP decreased significantly after reimbursement of catastrophic disease insurance; Catastrophic disease insurance and NCMS total effective reimbursement rate reached 84.8%; The NCMS compensation rate reached 68.9%, while fund incurred a financial deficit at the same time. Conclusion: Set deductibles, compensation rate and compensation range scientifically, and cancel ceiling level, improve the program of catastrophic disease insurance. Take measures to reduce the unfair between the districts and counties at city level. Establish effective link-up between catastrophic disease insurance and NCMS.