基于TOPSIS法的江苏省A市职工自费医疗补充保险补偿水平评价  

Evaluation of employee self-paying supplementary medical insurance compensation level of city A based on TOPSIS

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(School of International Pharmaceutical Business 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2期72-77,共6页Soft Science of Health

摘　　要：[目的]对江苏省A市自费医疗补充保险补偿水平进行评价,以期为我国自费医疗补充保险的补偿水平方案设计提供参考。[方法]通过文献研究得到补偿水平设置和评价的方法与指标,基于江苏省A市医保结算明细数据得到不同的方案和指标值,采用TOPSIS法评选最优补偿水平方案,通过最优补偿水平方案与江苏省A市现有补偿水平的比较进而评价A市自费医疗补充保险补偿水平的优劣。[结果]TOPSIS评价结果显示,江苏省A市的自费医疗补充保险筹资缴费率在0.4%的水平下,自费医疗补充保险补偿水平最优方案为不设起付线、封顶线在50万元以上或不设封顶线、报销比例为55%。[结论]江苏省A市当前的自费医疗补充保险设置的起付线和封顶线与最优方案一致,报销比例略低于最优方案,整体补偿水平较为合理;报销比例控制在45%~55%,能实现基金运行平稳和患者待遇保障良好之间的平衡。Objective Evaluate the compensation level of self-paying supplementary medical insurance in city A of Jiangsu Province,in order to provide reference for the project design of compensation level of self-paying supplementary medical insurance in our country.Methods The methods and indicators of compensation level setting and evaluation were obtained through literature research based on different scheme and index value from detailed data of medical insurance settlement in city A.It used TOPSIS method to appraised and elected the optimal compensation level plan,and evaluated good and bad of self-paying supplementary medical insurance in city A through the comparison between the optimal compensation level plan and compensation level now available.Results TOPSIS evaluation results showed that the payment rate of self-paying supplementary medical insurance financing in city A was below 0.4%.The optimal plans for the compensation level of self-paying supplementary medical insurance were that no starting line and capping line was over 500,000 yuan,or no capping line and the reimbursement ratio was 55%.Conclusions The starting and capping line of self-paying supplementary medical insurance settlement now available are same as the optimal plans,the reimbursement ratio is a little bit lower than the optimal plans,overall compensation level is relative reasonable;The reimbursement ratio is controlled between 45%and 55%which can achieve a balance between stable fund operation and good guarantee for patient’s treatment.

关 键 词：自费医疗补充保险 补偿水平 TOPSIS 

分 类 号：R19-0[医药卫生—卫生事业管理]