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论文编号：	3898
作者编号：	2120092763
上传时间：	2011/12/4 9:00:30
中文题目：	基于道本管理思想的我国现行医疗保险管理体制研究
英文题目：	Study of Applying the Dao-Oriented Management Theory to the Management Practice of Modern Medical Insurance in China
指导老师：	齐善鸿
中文关键字：	医疗保险 道本管理 提升模式
英文关键字：	Medical Insurance Dao-Oriented Management Upgrade Mode
中文摘要：	摘要医疗保险体系是社会保障中的一个重要组成部分，它与环境保护和可持续发展问题成为当今世界的热门话题。医疗保险问题不仅关系到人权保障的基本内容也与国家的稳定、发展和提高生产效率等方面息息相关。医疗保险是社会保障系统中最为复杂的方面之一，中国的医改自改革开放以来方兴未艾，已经成为社会建设中的一个复杂构成要件，鉴于此，人们花费大量精力研究医疗保险管理问题就具有重要的现实意义。近年来的医疗体制改革，除医疗保险体制改革外主要涉及四大领域，分别是健康问题改革、医疗服务提供方和药品供应方的改革。医疗保险体系通过其自身的规章与条文使其他三个体系联系并相互作用。基本医疗保险体制是全国范围内的政策体系，它是基于第三方支付的资金筹集系统，同时又是医疗保障的主要财务来源。虽然当今的医保系统没有实现全覆盖，但在过去五年中医疗保障系统已经以极快的发展速度覆盖了农村和城镇。我国政府宣称在2011年将实现医保系统的基本全覆盖，截至目前为止，这项任务已经出色的完成。与此同时，主要定位于高收入人群的商业医疗保险也方兴未艾。我国基本医疗保险的构成可以概括为三大方面：启动于1998年的城镇职工基本医疗保险；2003年政府启动的主要覆盖人群为农村居住人口的新农合医疗保险；自2007年开始覆盖老人、学龄前儿童和学生的城乡居民保险。其中城乡居民保险虽然原则上是对所有城乡居民实现全覆盖，但截至目前为止，由于各种原因的存在参保人群还没有达到既定要求。这三种医疗保障制度相互独立，在资金征缴、支付、和积累方面不尽相同。中央政府负责医疗保险政策制定和监管，地方政府则根据当地的经济和人口特征对政策进行原则范围下的调整。本文以基本城镇职工医疗保险为研究对象，做代表性研究。城镇职工基本医疗源自计划经济时代的公费医疗，它又可以分为免费医疗和劳工医疗。免费医疗建立于1952年社会主义改造基本完成之后，主要服务人群为政府公务人员，财政来源主要来自中央和地方政府，参保公务员要到定点医院去看病和向医生开具处方。劳工医疗建立于1951年，覆盖人群主要为生产领域的员工，和免费医疗一样，劳工医疗也提供免费医疗服务，不同的是，它是由雇主提供财务支持。另外，劳工医疗还为参保职工的家属负担50%的医疗费用。在上述这个医疗体制下，我国的医疗保险实现了“广覆盖”。可是因为没有合理的成本管控机制，过度医疗、道德风险和其他不良现象蔓延，导致了医疗支出的大幅攀升。历史数据表明：1980至1984年间的免费医疗支出增长了10.7%。而且，据估计每年被浪费掉的医疗资源占到总资源的20—30%。尽管在计划经济时代医疗福利制度达到了他的公平性和可及性，但是巨大的财政负担使政府和企业举步维艰。1994年，国务院在江苏省浙江市和江西省九江市进行了基本医疗体制的改革试点。这项改革从几基本上转变了中国的医疗保险体制，它是一项从所有人全覆盖到基于职工收入水平的社会保险。经过了4年的试验期，该项政策于1998年在全国推广，同时给予地方政府在支付、药品目录、诊疗目录和其他项目上以一定调整权限。近些年，医疗保险制度建设方面存在的问题层出不穷，建设稳固、有效地医疗保险管理体系成为一项迫切的社会任务。稳固健全的医疗保险制度不仅关系到国家的稳定繁荣，也涉及到人民群众的福祉。文中，作者分析了当今中国和世界其他国家的医疗保险体制，并且对于涉及此类的基本问题做了总结和归纳。无论是西方发达国家还是第三世界的发展中国国家，无一例外的都面对着医保改革的问题。经过多年的发展，我国的基本医疗保障体系已经构建，并且我们的体制改革正朝着正确的方向发展。同时，我国的医疗保险取得了令世人瞩目的惊人成绩，医疗保险促进社会保障的作用日益彰显。但总体来讲，许多困难仍然存在，许多问题亟待解决，医疗保险体系仍不能满足人民群众日益增长的需求，加之医疗保险制度的内在缺陷：“以药养医”问题的存在，这些都成为了医保改革的内在动力。鉴于医保制度改革是构建和谐社会主义社会的必然要求，所有这些问题都向我们的政府提出了严峻的挑战。“人人平等享有”是社会保险法的基本原则，所以，作为医疗保险管理者应该想尽办法解决医疗保险改革中的诸多问题，这一切理所当然的使医保改革成为当前工作的重心。基于上述考虑，笔者将道本管理思想应用于医疗保险管理实践中，以期能提升医务工作者的责任意识，本文行文框架如下：首先，在对医疗保险研究现状进行归纳和分析的基础上，提出本文选题的理论和现实意义，并说明本文的研究方法和行文框架；其次是相关理论准备，介绍了道本管理理论提出的原因、产生的背景、含义、思想主张、以及如何在医疗保险管理中体现出制度与道德两方面的管控；然后，在对我国医疗保险体制予以分析后得出医疗保险管理中存在诸多问题的原因以及对其进行道德管控的可行性。接下来，是本文的核心：指出坚定不移的执行各项规章制度是医保政策不可变更的基本准则，同时，基于道本管理，笔者探讨了道德问题的几个方面：医务工作者的责任意识、人性化管理、管理者与医务工作者的精神领域等，并且指出上述诸方面的相互作用；第五部分笔者构建了道本管理对于医保改革的提升模式：基于道本管理理论，笔者分别从指导思想、具体措施等方面对医疗保险管理制度进行综合考虑及给出建议。结语部分对以上论述进行总结，同时指出本文研究的不足和有待进一步深入探讨的问题。关键词：医疗保险 道本管理 提升模式
英文摘要：	Abstract The medical insurance system is an important component of social security and is becoming a hot topic along with environment protection and sustainable development in this world. It is not only the essential content of protecting basic human rights, but is associated to the stability, productivity and development of the society. In fact, it is the most complex system in different kinds of social securities. Medical treatment insurance reform in china has kept on developing after the policy of reforming and opening up．As it is the most complex construction of society system, people have paid more attention to it than other issues, and the study of building up the civil medical insurance system has become more meaningful. According to the latest Chinese Healthcare Reform Plan, the medical insurance system is one of the four components of the healthcare sector. One of the proposed reforms focuses on issues of public health, the medical service delivery system, and the pharmaceutical supply system (Healthcare Reform Plan, 2009). The medical insurance system makes the other three components of the healthcare sector interact with each other in the provision of healthcare. Basic social medical insurance (BSMI) is the countrywide government system that serves as the primary third-party payer and the backbone for healthcare financing. Although BSMI does not yet provide universal coverage, the program has been expanding rapidly into both rural and urban areas in China over the past 5 years. The government has already proclaimed that universal coverage through BSMI will be achieved by 2011. In the meantime, commercial health insurance, which currently targets the upper class, is in its nascent stages. BSMI consists of three schemes, including the basic social medical insurance scheme for urban employees initiated in 1998; the New Rural Cooperative Medical Insurance for Rural Residents program, which was officially established in 2003; and the basic social medical insurance for urban residents program covering mainly the elderly, students and children, which has been under a trial program in seventy-nine cities since 2007. The basic social medical insurance for urban residents program in principal includes all Chinese citizens, and yet there are still people who remain uninsured. Hence, this is not a comprehensive system. There are three schemes that segment people into three groups: rural residents, urban employees, and unemployed urban residents. Meanwhile, the three schemes function independently, differing in aspects related to financing, reimbursement, and expansion. Despite some of the central government's oversight, the local governments have the autonomy to make adjustments according to local economic and demographic status. As a result, the three schemes also vary across regions within China, with significant differences in the growth and policies of each particular scheme. The paper will introduce the three schemes individually. The basic medical insurance scheme for urban employees evolved from the Free Medical Service program and the Labor Medical Service program, which date back to the planned economy era. Founded in 1952, the Free Medical Service program, which was financed by the central and local governments, was mainly designed for civil servants. Those covered under the program had to visit designated hospitals in order to obtain prescription medication as well as free inpatient and outpatient services. The Labor Medical Service program was founded in 1951, covering employees in industrial enterprises. Similar to the Free Medical Service program, the Labor Medical Service program also provided free services for its members; however, it was financed by employers. In addition, the program reimbursed half of the medical expenditures of the members' families. Universal coverage was achieved under the welfare healthcare system; however, without appropriate cost-cutting mechanisms, over-utilization, moral hazard, and free-riders became prevalent, contributing to soaring increases in health expenditures. Historical data show that the annual increase in Free Medical service expenditures from 1980 to 1984 was 10.7% (Liu & Wang, 1991). Moreover, it was estimated that wasteful medical expenses accounted for 20–30% of total health expenditures (Liang, 2003). Despite the equality and accessibility the welfare healthcare system attained in the planned economy, the government and enterprises struggled with the immense financial burden of these two systems, driving the need to reform the system. In 1994, the State Council carried out pilot reforms of the basic social medical insurance scheme for urban employee in Zhenjiang City in Jiangsu Province and Jiujiang City in Jiangxi Province. This reform essentially transformed Chinese healthcare from a comprehensive national welfare system to a salary-oriented social insurance plan. After a four-year trial period, the scheme was launched throughout the country in 1998, with the local governments adjusting certain policies regarding reimbursement, drug formularies, list of services to be reimbursed, and other items. In recent years, the discussions about the problems of the medical insurance system keep coming up one after another, the construction of substantial medical insurance system becomes more and more urgent. Because the sound and solid medical treatment insurance is directly related to not only stable and prosperity of the country but the well- being of the people, in this dissertation, author analyzed the situation of medical insurance system in China and other countries, discussed about those issues and then made conclusions about basic methods and thoughts of modifying the civil medical insurance system. All of citizen, either of developed western countries or of developing the third world, face the pressing problem of medical treatment insurance. Through the construction reform for several years, our country’s basic medical guarantee system has already realized, and the system mechanism conversion is also on the right track. As a result, the medical treatment health system of reform has also obtained some striking progress, and the basic medical treatment insurance system of development already promotes function of social insurance. But there are lots of difficulties needed to be overcome in our countries. Total top see, society medical treatment insurance system still can’t satisfy the people’s increasingly demanding, and the flaw of medical treatment insurance itself has kept on existing: “doctor feed on prescription” is special scenery in china. All the difficulties put forward an austere challenge to the government in that medical insurance reform is the necessary demand of developing harmonious socialist society. As the managers of the medical treatment insurance, however, we must bravely accept this challenge since everyone in our country has the rights to enjoy the basic civil medical insurance, which is the principle of the Social Insurance Law. Medical treatment insurance reform perhaps is the most urgent mission today and is also a biggest item of the difficulty work. According to these considerations，the author tries to apply the Dao-Oriented Management to the management practice of medical insurance，hope to promote the awareness of responsibilities of medical workers．The frame structure of this thesis as follows： Firstly，it analyzes the current situation of medical insurance in the world，the actuality of the related study，illuminates the academic and realistic significance of this selected theme，and shows the research methods and frame．Secondly，focuses on the reasons for putting forward，background，connotation，in the meanwhile，explains the representative of rules and moral control．Thirdly，analyses feasibility of the moral control，and there are many more reasons of the crisis to the medical insurance，but the most important reason is the management model．For resolving the contradiction，the author introduces the Dao-Oriented Management and establishes the management model suit for the development rules of this field．The next section is the core of the thesis．The author insisted on observing the rules and regulations of medical insurance and inferred that it is the unmoved principle of everyday management. At the same time, on the basis of the Dao-Oriented Management，the author also analyses different perspectives of moral issue：awareness of responsibility of the medical workers，humanized management model，spiritual realm of managers and medical workers，these perspectives interact each other. The fifth chapter build the upgrade mode of medical insurance management on the basis of the Dao-Oriented Management, explains the use of the model，the principle of use and the attention in the process of using the model．Epilogue summarizes the above contents，and points out the insufficiencies of this research and issues that should be discussed further． Keywords：Medical Insurance Dao-Oriented Management Upgrade Mode
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