基于筹资精算模型的江苏省A市自费医疗补充保险制度优化研究  

Research on the optimization of supplementary insurance system for self-paying medical cost in city A of Jiangsu Province based on the fund-raising actuarial model

作　　者：钟港棚 徐伟[1] 汪宁 曹婷 何仁鑫 ZHONG Gang-peng;XU Wei;WANG Ning;CAO Ting;HE Ren-xin(International Pharmaceutical Business School of China Pharmaceutical University,Nanjing Jiangsu 211198,China)

机构地区：[1]中国药科大学国际医药商学院,江苏南京211198

出　　处：《卫生软科学》2022年第1期72-77,共6页Soft Science of Health

摘　　要：[目的]对A市自费医疗补充保险制度进行优化研究,以期为我国自费医疗补充保险制度的发展完善提供参考。[方法]采用描述性统计法对A市自费医疗补充保险的运行现状进行分析,并运用筹资精算模型从报销比例、支付范围和个人负担封顶线三方面对自费医疗补充保险制度进行优化设计。[结果]A市自费医疗补充保险报销比例较高,最优报销比例为50%;支付范围扩大到门诊后,2021-2025年缴费率为0.4519%,小于现行0.5%的缴费率政策;保障住院自费费用时,个人负担封顶线为30000元;同时保障门诊和住院自费费用时,个人负担封顶线为40000元。[结论]A市自费医疗补充保险基金充足,可通过扩大支付范围、设置个人负担封顶线等措施进一步提高患者的待遇水平和医保基金的使用效率。Objective To study the optimization of supplementary insurance system for self-paying medical cost in city A so as to provide reference for the development and improvement of supplementary insurance system for self-paying medical cost in China.Methods It used descriptive statistics method to analyze current operating conditions of supplementary insurance system for self-paying medical cost in city A,and used the fund-raising actuarial model to optimize the design of supplementary insurance system for self-paying medical cost from three aspects of reimbursement ratio,payment scope and seal top line of personal burden.Results The reimbursement ratio of supplementary insurance for self-paying medical cost in city A was relatively high,and the optimal reimbursement ratio was 50%;The payment rate was 0.451,9%from 2021 to 2025 when the payment scope was expanded to outpatient service,which was less than current policy payment rate of 0.5%.The seal top line of personal burden was 30,000 yuan when self-paying expenses of hospitalization were guaranteed;And the seal top line of personal burden was 40,000 yuan when the self-expenses of outpatient and hospitalization were guaranteed.Conclusions The supplementary insurance fund for self-paying medical cost in city A is sufficient,it may further improve patient's treatment level and use efficiency of medical insurance funds through expanding the scope of payment,setting seal top line for personal burden and so on.

关 键 词：自费医疗补充保险 报销比例 支付范围 个人负担封顶线 筹资精算模型 

分 类 号：R19-0[医药卫生—卫生事业管理]