新疆地区社会医疗保险费用支付办法研究

The the relevant departments of the government have tried various health care reform models to deal with the issue of the fast increasing medical expenses. In 2011, the Ministry of Health expanded the trial measures for the settlement of medical insurance expenditure in 40 regions all over the country: Diseases Related to Groups (DRGs) and outpatient settled according to individuals. In theory, DRGs can control excessive growth of medical expenses. A mathematical model of DRGs is established in this project to study grouping methods and upper limit of payment, trying to find ways to overcome the defect of DRGs. Payments related to groups need to solve two key problems: the first one is the selection of grouping variables and risk homogeneity tests, and the second one is the reasonable setting of upper limit of payment. Single disease payment system can be transformed into the mathematical model: grouping by statistical methods and setting upper limit of payment by actuarial optimization model. The prepayment system of medical expenses aims to encourage doctors to reduce the medical expences. We put forward proposals to deal with the situation in which patients' interests are harmed and measures of payment based on medical institutions' credit ratings. Medical institutions with different credit ratings have different upper limit of payment, and Ministry of Health join forces with social security institutions. The above two measures force hospitals to improve the quality of the human resource. Thus, the medical expenses can increase in a guided and reasonable way. In addition, three key techniques- - Collective Risk Model, non-parametric test and homogeneity test standard are applied to study and analyse the mixed payment with the Credibility model and stochastic simulation are used to study the situation of mixed payment and verificate models.

2011年卫生部在全国40个地区推广医疗保险费用结算办法试验：按病种分组付费（DRGs）和门诊按人头结算,目的是控制医疗费用的不合理增长.理论上DRGs用预付费制引导医生做减法，来减轻患者负担,也可以缓解先看病后付费院方风险。本课题通过建立DRGs的数学模型，研究分组方法和确定支付上限，并尝试克服DRGs付费方式缺陷的途径。分组付费要解决二个关键问题；一是分组变量的选取和风险同质性检验，二是支付上限的厘定。单病种付费制亦可转化为数学模型进行研究,用统计方法分组，支付上限用精算优化模型.宏观付费支付方式采用信度模型和广义线性模型。我们提出了损害患者利益时的处理建议和按医疗机构信用等级付费办法。不同信用等级有不同的支付上限，卫生主管部门与社保机构联合，通过支付方式迫使院方加强队伍建设，控制医疗费用的合理增长。关键技术是聚合风险模型、非参数检验，同质性检验标准。用随机模拟验证模型。

医疗保险最早的确立是以劳动者为保险对象的社会保险制度，其确立的目的是为了解除劳动者的疾病医治的担忧，避免劳动者在生病期间经济上的内外交困的窘境。2011年我国卫生部在全国40个地区推广医疗保险费用结算办法试验：按病种分组付费（DRGs）和门诊按人头结算。以此控制医疗费用的不合理增长，引导医生减轻患者负担。本课题在新疆乌鲁木齐市2010年选定22个病种进行了DRGs改革尝试。解决了以下问题：第一，付费方式以患者年龄、疾病诊断、合并症、并发症、治疗方式等因素将患者进行分组，并且进行同质性检验，进而确定最高付费限额。第二，从损失分布角度进行深入分析，对分组后不同组的分布进行假设检验或非参数拟合，最终确定其分布类型，确定合理的支付限额。第三，结合卫生主管部门对医疗机构的信用评级确定其支付上限，通过建立DRGs的数学模型，控制医疗费用的合理增长。另外，对混合支付方式采用信度模型进行研究和分析，同时，将链梯法与损失进展 Cape Cod方法结合，将链梯法中的进展因子作为随机变量进行研究，再与损失进展 Cape Cod方法结合来估计准备金。最后，应用扭曲风险度量、AVaR等风险度量来研究保险，得到一个完善的风险评估体系。找到一种能被医、患、保险部门三方都能接受的付费方式，控制医疗费用适度增长，进而研究各种医疗费用结算办法对财务平衡的影响，为相关职能部门制定政策提供科学依据。

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