城乡居民医保制度的性质、运行机制及对医疗服务市场的影响  

The Nature,Operation Mechanism and Impacts on Medical Service Market of Medical Insurance for Urban and Rural Residents

作　　者：谭秋成[1] Tan Qiucheng

机构地区：[1]中国社会科学院农村发展研究所

出　　处：《复印报刊资料（社会保障制度）》2023年第12期77-89,共13页SOCIAL SECURITY SYSTEM

基　　金：中国社会科学院创新工程项目“基层治理数字化转型研究”(No.2022NFSB01)。

摘　　要：在城乡居民医保中,中央政府制定规则,地方根据实际执行规则,居民则根据制度规定好的权利和义务自愿选择参保与否。城乡居民医保由政府管理必然要满足医保之外政府其他有关医疗卫生发展的需要,医保部门通过调节医疗机构垄断租金和政府补助这两大工具来协调医保服务与政府其他医疗卫生发展目标之间可能发生的冲突。城乡居民医保具有区域性,是交一年保费购买一年保险服务,提供的保险品种是单一的。除共付制、起付线和封顶线外,城乡居民医保还设立门诊和住院次均费用、按床日付费,按人头付费等用于考核医院的指标,目的是控制费用,扩大受益人群,防止医院过早、过快花完医保资金。城乡居民医保不存在所谓需求方道德风险问题。城乡居民医保制度建立后,医疗服务价格无论在长期还是短期,上涨是必然趋势。因为大量医保资金突然投放在统筹区,导致更多的资金购买而医疗服务供给不变或增加有限,形成类似于通货膨胀的价格上涨效应。医保制度增加了社会资本进入医疗领域的难度,限制了公立医院之间的竞争,妨碍了分级诊疗和医疗机构之间有效的分工协作。改革城乡居民医保的组织方式和运行机制的主要内容是建立家庭账户,即以家庭为单位,参保成员共同设立一个账户,投保金额可多可少,政府按投保金额一定比例补助。家庭账户的医保基金每年结余可转存累积,家庭成员寻医问诊可自主选择医院。In medical insurance for urban and rural residents,the central government formulates rules,local gov-ernments implement rules,and residents voluntarily choose to participate in insurance in the face of the rights and obligation stipulated by the system.The medical insurance for urban and rural residents is managed by the government,so it has to realize other government's wills related to medical and health development beyond medical insurance.Medical insurance agency coordinates the possible conflicts between medical insurance service and the government's other medical and health development goals by using two major tools,namely adjusting monopoly rent in medical insti-tutions and government subsidies.The medical insurance for urban and rural residents has regional characteristics,residents pay a one-year premium to purchase a one-year insurance service,and it provides single insurance service.Except for the copayment system and the reduction and top lines,the medical insurance for urban and rural residents sets up such indicators as average outpatient and inpatient expenses per time,expenses paid per bed a day and per head to assess hospitals.The purpose is to control expenses,expand the beneficiary population,and prevent hospitals from exhausting medical insurance funds too fast and too early.There doesn't exist moral hazard from the demand in the medical insurance for urban and rural residents.As the medical insurance for urban and rural residents is set up,price rising of medical service,whether in the long or short term,is an inevitable trend.Because a large amount of medical insurance funds have suddenly been invested in the overall planning area.This leads to much more purchase but the supply of medical services remains unchanged or increases limited,and forming a price increase effect similar to inflation.The medical insurance system has increased the difficulty for social capital to enter the medical field,restricted the competition among public hospitals,and obstructed graded diagnosis and treatment and

关 键 词：城乡居民医保 医疗服务供给 医疗服务需求 家庭账户 

分 类 号：F842.684[经济管理—保险] R197.1[医药卫生—卫生事业管理]