基于系统动力学的增强门诊共济保障功能后职工基本医疗保险基金水平预测分析

Simulation Analysis on Pooling Funds of Urban Employees Basic Medical Insurance After Increasing Outpatient Social Security Based on System Dynamics Analysis

目的:基于增强门诊共济保障功能的新政策,预测广州市、深圳市和肇庆市职工基本医疗保险统筹基金结余和个人账户余额变化,为政府部门制定医保政策提供依据。方法:基于系统动力学理论,构建系统动力学模型进行预测和政策模拟。结果:若无政策干预,职工医保统筹基金结余和个人账户余额将逐年减少。在政策模拟降低个人账户划入比例、提高门诊统筹划入比例和支付比例后,职工医保统筹基金结余有所增加,个人账户余额将减少,且统筹基金的门诊支出增加、住院支出减少。结论:对于统筹基金结余充足的城市,降低个人账户划入比例、同时提高门诊统筹划入比例和支付比例的方案更合适。对于统筹基金紧缺的城市,降低个人账户划入比例、仅提高门诊统筹划入比例的方案更符合实际。

Objective:To predict the changes in the balances of Urban Employees Basic Medical Insurance(UEBMI)pooling funds and personal medical savings account(MSA)balances based on the newly issued policy of enhancing the outpatient social security function in Guangzhou,Shenzhen and Zhaoqing City and provide recommendations for the formulation of medical insurance policies for relevant government departments.Methods:According to the system dynamics theory,a system dynamics model is established to predict the balances and simulate different policy implementation.Results:In the absence of policy intervention,the balances of UEBMI pooling funds and personal MSA balances would decrease annually.The simulation results indicated that after reducing the contribution rates of personal MSA,and increasing both the contribution rates and reimbursement rates of the outpatient pooling funds,the balances of UEBMI pooling funds would increase and the balances of personal MSA would decrease.In addition,the outpatient expenditures of UEBMI pooling funds would increase while the inpatient expenditures would decrease.Conclusion:Regarding those cities with sufficient pooling funding,it would be preferable to reduce the contribution rates of MSA while increasing both the contribution rates and reimbursement rates of outpatient pooling funds.For cities lack of pooling funding,it would be more realistic to reduce the contribution rates of MSA while increasing only the contribution rates of outpatient pooling funds.