国家医疗保障风险调剂金的制度理性与现实选择  

The National Health Insurance Risk Adjustment Fund:Institutional Rationality and Realistic Choice

作　　者：王琬[1] Wang Wan(School of Insurance,University of International Business and Economics,Beijing 100029,China)

机构地区：[1]对外经济贸易大学保险学院

出　　处：《社会保障评论》2022年第6期68-84,共17页Chinese Social Security Review

基　　金：对外经济贸易大学优秀青年学者资助项目(18YQ13)

摘　　要：国家医疗保障风险调剂金是分散健康财务风险、促进公平竞争、保障待遇一致性的重要措施。本文从制度理性视角阐释了我国建立国家医疗保障风险调剂金的合理性与必要性。基于对国内区域性医疗保障风险调剂金地方试点的考察,分析了制度实践的初步成效与现实困境。通过对欧美发达国家经验的总结,评估了制度建立的可行性及其影响因素。在此基础上,进一步探讨了国家医疗保障风险调剂金制度构建的目标原则,提出了职工医保风险调剂金和综合医保风险调剂金两种可供选择的实施方案,并进行了初步测算。立足健康中国发展战略与医保改革大方向,基于财政筹资、覆盖全民的综合型国家医疗保障风险调剂金更能体现公平性,应成为中国特色医疗保障制度体系中的重要制度安排。当前,应积极做好构建国家风险调剂金制度的充分准备,推进其向着规范化、科学化、法治化、信息化的方向发展。The establishment of a national health insurance risk adjustment fund is an important measure to spread financial risks,promote fair competition,and ensure the consistency of benefits.This paper explains the rationality and the necessity of establishing a risk adjustment mechanism in China’s health insurance from the perspective of institutional rationality.Based on the review of local pilots,this paper analyzes the initial progress and problems of the mechanism.By summarizing the experiences of selected European countries and the United States,this paper discusses the feasibility of introducing the national risk adjustment fund and its infl uencing factors.The paper further discusses the targets and principles of the construction of the national health insurance risk adjustment fund,proposes two alternative implementation plans,and makes preliminary calculations.The paper holds that the comprehensive national risk adjustment fund,in line with the Healthy China initiative and the direction of health care reform,which is funded by the government and covers the whole population,is an optimal choice.Relevant preparations need to be made at the current stage for the sound development of the national health insurance risk adjustment fund.

关 键 词：医疗保障 国家风险调剂金 制度理性 发展路径 

分 类 号：R197.1[医药卫生—卫生事业管理] F842.684[医药卫生—公共卫生与预防医学]