管理型医疗保险方案与补偿型健康保险方案的比较研究  

Comparatively studying on managed care plan and compensatory plan of health insurance

作　　者：代宝珍[1,2] 周绿林[1,2] 余悦[1] 

机构地区：[1]江苏大学管理学院,江苏镇江212013 [2]江苏大学新农村发展研究院

出　　处：《中国卫生事业管理》2013年第9期663-664,673,共3页Chinese Health Service Management

基　　金：国家自然科学基金"基于农村医疗保障制度的老年居民慢性病管理模式研究"(编号:71203080);江苏大学高级专业人才科研启动基金(编号:12JDG122);中国博士后科学基金[(编号:2013M530242);江苏省博士后科研资助计划]

摘　　要：管理型医疗是已被国外普遍证实的控制成本、提高保险公司利润的一种卓有成效的保险方案。它要求保险人与保险计划的提供者更多的了解和掌握评价医疗服务的技能。它通过市场竞争和选择与医疗服务供方实现风险分担,由特定的组织结构和管理手段达到控制成本的目的,并取得几乎没有差别的医疗质量。传统的补偿型健康保险方案采用的是按服务项目付费的事后理赔计划。由于按服务项目付费的相关医疗决策几乎完全由医生和患者进行,且技术上很难确定合理的服务总量,这就在很大程度上增加了难以控制的道德风险。文章介绍了管理型医疗的定义及主要组织形式,着重从支付方式、医疗质量、合作医疗机构的选择等3个层面与传统的补偿型健康保险方案做了全面深入的比较研究。Managed care system has already been confirmed as an effective insurance plan to control cost and improve profits for insurance company, which requires the provider of insurer and insurance plan further understand medical services techniques. By market competition and sharing risk with medical service provider,with given organization and management, it can atlain the purpose of controlling cost and almost no difference of medical treatment quality. While the traditional compensatory health insurance plan adopts the method of fee for service, that is compensatory after the event, which is almost decided by doctors and patients and diflqeult to define reasonable service quantity,thus results in morality risk. The definition and main organizations of managed care system were introduced. And it was comparatively studied with traditional compensatory health insurance plan, mainly from aspects of payment, medical treatment quality and selection of cooperative medical organization.

关 键 词：管理型医疗 按服务项目付费 健康保险 成本 

分 类 号：R197.1[医药卫生—卫生事业管理]