[1]沈思远,李 华.“门诊共济”时代上海市职工医保基金收支风险评估与应对[J].卫生经济研究,2023,40(1):34-41.
　SHEN Siyuan,LI Hua.Assessing and Responding to the Risks of Income and Expenditure of Shanghai Employees' Medical Insurance Fund in the Era of Outpatient Co-payment[J].Journal Press of Health Economics Research,2023,40(1):34-41.
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“门诊共济”时代上海市职工医保基金收支风险评估与应对
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卫生经济研究[ISSN:1004-7778/CN:33-1056/F]

卷:
40
期数:
2023年1期
页码:
34-41
栏目:
医疗保障
出版日期:
2023-01-06

文章信息/Info

Title:
Assessing and Responding to the Risks of Income and Expenditure of Shanghai Employees' Medical Insurance Fund in the Era of Outpatient Co-payment
作者:
沈思远1; 李 华2
1.上海交通大学医学院附属上海儿童医学中心，上海 200127
2.上海财经大学公共经济与管理学院，上海 200433
Author(s):
SHEN Siyuan;  LI Hua
Shanghai Children's Medical Center, School of Medicine, Shanghai Jiao Tong University, Shanghai 200127, China
关键词:
门诊共济; 职工医保; 风险管理; 精算分析
Keywords:
outpatient co-payment;  employee health insurance;  risk management;  actuarial analysis
分类号:
F840.684；R197
文献标志码:
A
摘要:
以职工医保风险因素较为典型和突出的上海市为例，构建精算模型，实证评估“门诊共济”时代职工医保基金的收支风险，并通过政策模拟，为应对风险提供建议。结果显示：职工医保基金中短期和长期风险存在差异，按现行政策，职工医保基金将在2035年前收不抵支、出现亏空；统账之间风险不同，统筹账户收支倒挂、穿底风险显著，个人账户结余过多、资金使用低效；“门诊共济”相关改革可以降低基金结构方面的风险；配合人口（激励生育、放松迁入限制）、医保支付（控费）、筹资（延迟退休、退休人口缴费）等政策，“门诊共济”相关改革能更大程度避免基金收支风险，有助于基金高效、持久运行。
Abstract:
An actuarial model was constructed to empirically assess the risks to the income and expenditure of the employees' medical insurance fund in the era of "outpatient co-payment", taking Shanghai as an example, where the risk factors of the employees' medical insurance are typical and prominent, and to provide suggestions to cope with the risks through policy simulation. The results show that there is a difference between the short- and long-term risks of the employees' medical insurance fund, with the current policy indicating that the fund will not be able to cover its expenses and will be in deficit by 2035. The risks between the unified account and the account are different, with the risk of inversion of income and expenditure and significant risk of undercutting of the individual account, and the risk of excessive balance and inefficient use of funds. The reforms related to "outpatient co-payment" can reduce the risks in the structure of the fund. Together with policies on population (incentives for childbirth, relaxation of restrictions on migration), health insurance payments (fee control) and financing (delayed retirement, contributions from the retired population), the reforms related to "outpatient co-payment" can avoid to a greater extent the risks of income and expenditure of the fund and help the fund to operate efficiently and sustainably.

参考文献/References:

[1] 曾雁冰.老龄化背景下我国医疗保险制度的系统动力学研究[J].中国卫生统计，2018（6）：811-816.
[2] 曹信邦，王建伟.风险：我国社会保障面临的挑战[J].税务与经济，2004（1）：19-23.
[3] 邓大松，薛惠元.社会保障风险管理国际比较分析[J].学习与实践，2011（2）：110-120.
[4] 曾益.老龄化背景下城镇职工基本医疗保险基金财务运行状况的精算预测——对“全面二孩”政策效应的评估[J].中囯卫生政策研究，2019，12（1）：9-18.
[5] 曾益.人口老龄化背景下我国城镇职工基本医疗保险制度可持续性研究[D].上海：上海财经大学，2014.
[6] 何文炯，杨一心，刘晓婷，等.社会医疗保险纵向平衡费率及其计算方法[J].中国人口科学，2010（3）：88-94.
[7] 张心洁，周绿林，刘彤彤.城乡居民基本医疗保险制度整合后的基金可持续性研究[J].中国卫生经济，2019（2）：30-33.
[8] 李亚青，申曙光.退休人员不缴费政策与医保基金支付风险——来自广东省的证据[J].人口与经济，2011（3）：70-77.
[9] 文裕慧.城镇职工基本医疗保险退休人员适当缴费研究[J].现代管理科学，2015（10）：91-93.

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更新日期/Last Update: 2023-01-06