医保基金有效使用:风险管理、国际经验与政策建议  

Effective use of health insurance funds: Risk management,international experiences and poli- cy recommendations

作　　者：董丹丹[1] 孙纽云[1] 孙冬悦[1] 房珊杉[1] 梁铭会[1] 

机构地区：[1]卫生部医院管理研究所,北京100191

出　　处：《中国卫生政策研究》2013年第1期21-27,共7页Chinese Journal of Health Policy

摘　　要：医保基金有效使用是医疗保险制度运行管理的核心,本文分析了我国医保基金有效使用与管理过程中人口老龄化、价格上涨、社会福利政策完善所致医疗需求释放等外部风险因素以及医保系统本身的运行风险,总结了国际上应对医保基金运行管理风险的经验,结合我国国情提出为确保我国医保基金有效使用应科学预估医保基金运行风险,合理确定医保筹集费率与补偿标准;提高医保基金统筹层次,提升基本医保互助共济水平;健全医保基金监测机制,提高基金使用效率;完善医保报销目录,加强医疗服务项目管理的相关建议,以期完善我国医保基金的管理。Effective management of the health insurance funds is the core of the operation and management of the medical insurance system. This paper comprehensive analyzed the risk in health insurance funds use and manage- ment. the risks include ageing, economic inflation, release of medical needs caused by Social welfare policy improve- ment and other external factors, as well as the internal factors in health insurance system. Furthermore, we summa- rized the advanced foreign experience during the health insurance funds operation and use. Finally, based on the fact of China, it proposed the advices on effective management of the health insurance funds such as to determine the medical insurance raise rate and compensation standard reasonably with estimating the medical insurance fund opera- tion risk scientifically, to develop the medical insurance relief level with improving the insurance overall level, to im- prove the efficiency of funds use with establishing the health insurance funds monitoring mechanisms, and to strength- en medical service project management with Improving medical insurance reimbursement directory.

关 键 词：医保基金 费用管控 效率 

分 类 号：R197[医药卫生—卫生事业管理]