研制补偿方案:新型农村合作医疗保险方案研制思路之七

Developing reimbursement plans: ideas of developing NRCMS(Ⅶ)

为最大程度实现新农合制度目标,根据"特定人群就医概率—就医费用—就医经济风险—特定风险筹资水平—特定筹资下的补偿设计"的动态关系,形成了方案研制的思路与步骤:首先,在收支平衡的原则下,确保消除因病致贫所需的筹资额;其次,选择方案的风险保障性质,属于"风险型"、"福利型"还是"福利风险型";最后,根据确定的风险保障范围,明确补偿方案的风险共担约束机制,包括起付线、补偿比和封顶线,并确保分段补偿时消除特定风险后基金不透支。

To achieve the goals of the New Rural Cooperative Medical System（ NRCMS ）, the study formed the thoughts and procedures of developing reimbursement plans according to the dynamic relations between probability of hospitalization, medical expense, financial risk from medical expenses, funding level to address specific financing risk and reimbursement plans developed under specific funding level. Firstly, under the principle of financial break-even, the funding capital used on eliminating medical impoverishment was ensured; Secondly, the types of plans according to their risk insurance property were chosen; Finally, the constraint mechanism of reimbursement plans based on the scope of risk insurance coverage, including deductible, ratio of reimbursement and ceiling was defined. Meanwhile, no overdraft after eliminating specific risk in piecewise compensation was ensured.