云南省城乡居民大病保险现状问题及建议

The status,problems and suggestions on serious illness insurance in urban and rural residents in Yunnan Province

[目的]分析云南省大病保险工作现状存在的问题及其原因,为大病保险制度的稳定运行提供参考。[方法]通过数据采集、实地走访等方式,结合典型研究及医改监测报表数据,分析云南省大病保险工作现状。[结果]2014-2015年,云南省城镇居民基本医疗保险和新型农村合作医疗参保(合)率均达到98%以上。2015年较2014年筹资金额增长2.55%,大病保险实际赔付金额增长29.25%,大病受益人次增加46.03%,但大病保险筹资总金额仅增长2.55%。2015年较2014年住院费用增加了66888.7万元,增长14.75%。[结论]云南省城镇居民基本医疗保险和新型农村合作医疗基本实现全覆盖,大病保险体现出筹资金额、赔付金额、大病受益人次3个方面的稳步增长。但存在资金筹集机制不够完善、报销方式不够规范、基金使用对弱势群体的公平性有待提高、管理模式有待统一、医疗费用增长过快、对承办公司的监督管理有所缺失等方面的问题。建议:(1)提高统筹层次,统一筹资标准;(2)合理界定合规费用报销范围;(3)完善补偿机制,对低收入群体适当照顾;(4)发挥综合调控作用,控制医疗费用不合理增长;(5)健全考核评价体系,建立承办商保机构激励约束机制;(6)改进管办方式,有效发挥合署办公作用;(7)推进信息数据互联共享,提升大病保险管理经办水平;(8)加强政策宣传,营造大病保险发展良好氛围。

Objective To analyze current status,problems and causes of serious illness insurance work in Yunnan province so as to provide reference for stable operation of serious illness insurance system. Methods Through data collection,field visits and other ways,combined with typical research and medical reform monitoring report data,analyzed current situation of serious illness insurance work in Yunnan Province. Results From2014 to 2015,insured rate of basic medical insurance for urban residents and new-type rural cooperative medical insurance in Yunnan Province was over 98%. The amount of funds raised increased 2. 55% in 2015 compares with in 2014. The actual compensation amount of serious illness insurance increased 29. 25%. The number of serious illness benefit person-time increased 46. 03%. But the amount of funds raised only increased2. 55%. Hospitalization expense increased 668. 887 million yuan（ 14. 75%） in 2015 compared with in 2014. Conclusions It comes true nation-wide of basic medical insurance in urban residents and new-type rural cooperative medical insurance in Yunnan Province. Serious illness insurance shows steady growth in three aspects such as raised funds,compensation amount and serious illness benefit person-time. But it still has some problems as that funds raising mechanism is not perfect,reimbursement method is not standardized enough,fairness of funds use for disadvantaged groups needs to be improved,management model needs to be unified,medical expenses increase too fast,lack of supervision and management to contractors. Measures and Suggestions 1. Raise co-ordination level and untify funding standards. 2. Reasonably define the scope of reimbursement for compliance expenses. 3. Improve the compensation mechanism,and properly take care of low-income groups. 4. Play a comprehensive regulatory role to control unreasonable growth of medical expenses. 5. Perfect the assessment and evaluation system,and establish incentive and restriction mechanisms for commercial insurance agency. 6. Improve the management and management methods to effectively play a full role in office work. 7. Promote the interconnection and sharing of information and data,and improve the management level of serious disease insurance management. 8. Strengthen policy publicity,and create a good atmosphere for serious illness insurance.