基本医保省级统筹风险调剂机制研究——基于结构性风险与管理风险相分离视角  

Study on Risk Adjustment Mechanism of Basic Medical Insurance Pooling at Provincial Level——Based on Separation of Structure and Management Risk

作　　者：朱凤梅 贺方兴 

机构地区：[1]中国社会科学院经济研究所,北京100836 [2]赣州市医疗保障局监测中心,赣州341000

出　　处：《中国医疗保险》2023年第6期32-38,共7页China Health Insurance

摘　　要：目前,我国基本医保省级统筹不管是“统收统支”还是“调剂金”制度,都需要厘清“结构性风险”与“管理风险”之间的关系。本文在借鉴国际经验基础上,提出构建适合我国实际情况的省级统筹风险调剂方案,一是利用参保患者的年龄、性别、健康状况等特征分离出“结构性风险”;二是建立标准化风险支出模型,给出各统筹区基于结构性风险调剂后的“标准”基金支出公式,以分离出“管理风险”。在此基础上,本研究利用X样本省2013年—2019年医保结算数据,对上述过程进行论证,发现方案具有可操作性和可行性。建议各地在推进省级统筹的过程中,考虑将基金支出的结构性风险与管理风险相分离,统筹结构性风险,压实管理风险。同时,兼顾地区实际情况,防范基金逆向分配,保障制度公平。At present,both the“unified income and expenditure”and“adjustment fund”system of the basic medical insurance provincial planning need to clarify the relationship between"structure risk"and"management risk".Based on international experience,this paper proposes to construct the provincial pooling risk regulation plan suitable for the situation of China.First,the"structure risk"is separated by the age,gender,health status and other characteristics of insured patients.The second plan is to establish a standardized risk expenditure model,and give the"standard"fund expenditure formula of each pooling area based on structure risk adjustment,in order to separate the"management risk".The process above is demonstrated by further using the medical insurance settlement data of a sample province from 2013 to 2019,and it is found that the scheme is operable and feasible.It is suggested that in the process of promoting provincial pooling,the structure risk of fund expenditure should be separated from the management risk,and the structure risk should be coordinated and the management risk should be compacted.At the same time,regional realities should be considered to prevent reverse allocation of funds and ensure fairness of the system.

关 键 词：省级统筹 风险调剂 结构性风险 管理风险 

分 类 号：F840.684[经济管理—保险]