美国医疗保险承包商管理对我国基本医保经办管理的启示

Enlightenment from the Management of American Medical Insurance Contractors to the Management of Basic Medical insurance in China

目的:探究承包商制度的运行、管理模式、准入机制等,为我国基本医疗保险管理和经办提供借鉴。方法:采用调查法与比较分析法对材料进行评阅,并对中国和美国基本医疗保险制度进行对比,得出美国医疗保险承包商运行模式对我国基本医保经办的借鉴意义。结果:探索了美国基本医疗保险类型、医疗保险的委托管理模式、美国医疗保险的费用机制,剖析了美国对医保管理承包商的资助情况、对承包商的评价体系等内容。结论:引入社会化经办,构建小政府;明确政府和社会资源责任;建立完整的监管体系,确保制度平稳运行;发挥信息化作用,优化经办和监管流程,提升治理能力;多部门协同,推进筹资、经办和监管的发展,政务信息公开,发挥群众和社会各界力量,办好我国基本医疗保险等。

Objective: To explore the operation, management model and access mechanism of the contractor system through the investigation of the contractor system in the United States, so as to provide reference for the management of the basic medical insurance in China. Methods: The materials were evaluated by the method of investigation and comparative analysis, and the basic medical insurance systems in China and the United States were compared. Results: It explored the types of basic medical insurance in the United States, the mode of entrusted management of medical insurance, the cost mechanism of medical insurance in the United States, and analyzed the financial support for medical insurance management contractors in the United States and the evaluation system for contractors. Conclusion: Introducing socialized management to build a small government; clarifying the responsibility of government and social resources; establishing a complete supervision system to ensure the smooth operation of the system; giving full play to the role of information technology, optimizing the management and supervision process, and improving governance capacity; trans-department coordination to promote the development of financing, management and supervision, and government information disclosure It should give full play to the strength of the masses and all sectors of society, and do well in basic medical insurance in China.