基本医疗保险费用共付机制研究  

Study on Copayment Mechanism of Basic Medical Insurance

作　　者：田蒙蒙 TIAN Mengmeng(School of Law,Shandong University,Qingdao,Shandong,266237,China)

机构地区：[1]山东大学法学院,山东青岛266237

出　　处：《医学与社会》2023年第7期103-107,115,共6页Medicine and Society

基　　金：2021年度青岛市社会科学规划研究项目,编号为QDSKL2101002。

摘　　要：基本医疗保险在保基本的定位之下,参保人的医疗费用支出由基本医保基金和参保人共同支付,基本医保基金对参保人医疗费用支付最高限额的设计无限放大了个人自付责任,导致实践中出现“因病致贫、因病返贫”问题,理论上背离基本医保的制度目的。借鉴域外经验,医疗费用支付应从“有限的医保责任”转向“有限的个人责任”,且这种转变并不会导致基本医保基金的破产。在全民医保的背景下,基本医保基金垄断了医疗服务的购买力,可通过其优势地位进行集中带量采购以改变医疗服务的不合理高价,同时可通过完善支付标准、健全医疗服务审查规范以实现基本医保基金的可持续。Under the positioning of"basic guarantee"of basic medical insurance,the medical expenses of the insured are jointly paid by the basic medical insurance fund and the insured.The provision of the maximum payment limit of the basic medical insurance fund infinitely magnifies personal responsibility,this leads to the problem of"being impoverished due to illness and returning to poverty due to illness"in practice.In theory,it deviates from the purpose of the basic medical insurance system to protect residents'right to life and health.Drawing on the experience of extraterritorial systems,the payment of medical expenses should be changed from"limited medical insurance liability"to"limited personal liability",and this change will not lead to the bankruptcy of the basic medical insurance fund.In the context of universal medical insurance,the basic medical insurance fund monopolizes the purchasing power of medical services,and can use its dominant position to purchase quantity-for-price,thereby changing the unreasonably high price of medical services.At the same time,the sustainability of basic medical insurance funds can be achieved by improving payment standards and improving the medical service review system.

关 键 词：基本医疗保险 医疗费用 共付机制 个人自付 

分 类 号：R19-0[医药卫生—卫生事业管理]