【摘要】：隨著社會生產力的進一步發展和人民生活水平的不斷提高,社會保險在國民生活中發揮著愈來愈重要的作用。大病保險承擔著極其重要的社會保障職能,通過對重大疾病的報銷,重大疾病患者的經濟負擔得到了大大的減輕。近些年,城鄉居民大病保險正在以市場機制逐步進入到社會保障制度,并取得到了相當滿意的效果,同時在基本政策方面有了很大的進步,具有代表性的是:補償比例方面、融資籌集方面、費用處理方面、結算管理方面等。但是在實踐過程中,大病保險依然面臨種種考驗,商業保險公司承辦的大病保險在政策法規、籌資水平、政商系統對接、合作模式、隱性價格競爭等方面存在諸多問題。此外,大病保險在公共財政支出與商業保險公司之間的有效銜接仍然存有一些問題,這一點表現在公共財政的支付與商業保險公司的對接環節尤為明顯。本文希望通過從解決這些問題入手,將商業保險公司承辦的大病保險業務的核心問題得以理順。首先,本文以經營者地位的商業保險公司為視角,采取文獻分析法、比較分析法等研究方法,通過了解典型的幾個模式,更為清晰地分析商業保險公司在承辦大病保險業務活動時的真實狀況。并借此對目前我國商業保險公司在承辦大病保險過程中存在的問題從三個方面進行分析:政策法規不健全,如相關法律法規不健全、政府監管錯位越位現象時有發生、醫療保險政策缺乏整體性設計;大病保險基金浪費現象缺乏有效對策,如醫院“過度醫療”,監督管理方式單一、醫療信息缺少共享,“智能審核”應用水平有待增強、醫療保險支出績效評估不足,醫療保險效果定量分析不足;大病保險特點、機制、標準探究不足,導致大病醫療保障水平較低。最后,針對出現的問題提出一些對策和建議,不僅從政府的政策層面,配合多元利益需求,合理、科學建構整體法律框架;而且創新思路,加強對各參與主體的監管與考核,加強監管醫院“過度醫療”,推廣“智能審核”信息化手段運用,且引入第三方機構,對醫療保險效果進行評估;同時,隨著大病保險的推廣與深入研究,要綜合施策,提高大病保險保障水平,加強對大病保險特點的分析研究,建立商業保險與社會保險聯動工作機制,制定統一的大病保險保障標準。
[Abstract]:With the further development of social productivity and the continuous improvement of people's living standard, social insurance plays an increasingly important role in national life. The serious illness insurance plays an extremely important role in social security, and the financial burden of the patients with the major diseases is greatly reduced through the reimbursement of the major diseases. In recent years, urban and rural residents' serious illness insurance is gradually entering the social security system through the market mechanism, and has achieved quite satisfactory results. At the same time, great progress has been made in the basic policies. Financing aspects, cost handling, settlement management, etc. However, in the process of practice, the serious illness insurance still faces various tests. There are many problems in the policies and regulations, the level of financing, the docking of the government and business system, the cooperation mode, the hidden price competition and so on. In addition, there are still some problems in the effective connection between public expenditure and commercial insurance companies, which is especially obvious in the connection between public finance payment and commercial insurance companies. Through solving these problems, this paper hopes to straighten out the core problems of the serious illness insurance business undertaken by commercial insurance companies. First of all, from the angle of view of commercial insurance company with operator status, this paper adopts literature analysis, comparative analysis and other research methods to understand several typical models. A clearer analysis of the real situation of commercial insurance companies in undertaking major illness insurance business activities. In this way, the problems existing in the process of undertaking the insurance of serious illness in China's commercial insurance companies are analyzed from three aspects: the imperfect policies and regulations, such as the imperfect laws and regulations, the phenomenon of government supervision misplacing and offside, which occur from time to time. The medical insurance policy lacks the overall design, the serious illness insurance fund waste phenomenon lacks the effective countermeasure, such as the hospital "excessive medical treatment", the supervision and management way is single, the medical information is not shared, the application level of "intelligent audit" needs to be strengthened. The medical insurance expenditure performance evaluation is insufficient, the medical insurance effect quantitative analysis is insufficient, the serious illness insurance characteristic, the mechanism, the standard exploration insufficiency, causes the serious illness medical treatment safeguard level to be low. Finally, some countermeasures and suggestions are put forward to solve the problems, not only from the government policy level, to meet the needs of multiple interests, but also to construct the overall legal framework scientifically, and to create new ideas to strengthen the supervision and assessment of the participants. Strengthen supervision of hospital "excessive medical treatment", popularize the use of "intelligent audit" information means, and introduce third party organizations to evaluate the effect of medical insurance; at the same time, with the promotion and in-depth study of the insurance for serious illness, we should comprehensively implement countermeasures. To improve the level of insurance for serious illness, to strengthen the analysis and research on the characteristics of the insurance of serious illness, to establish the working mechanism of the linkage between commercial insurance and social insurance, and to formulate a unified standard of insurance for serious illness.
【學位授予單位】：山西大學
【學位級別】：碩士
【學位授予年份】：2017
【分類號】：F842.6

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