医保风险调剂金的国际经验及启示

International Experience and Implications of Risk Adjustment in Medical Insurance

保障不同保险项目覆盖人群的待遇一致性,是世界各国在实现全民健康覆盖(UHC)过程中追求的重要目标,也是医疗保障制度改革的重要原则。本文着眼于德国、瑞士、荷兰和美国四个欧美发达国家医疗保险风险调剂机制的形成背景、应用场景和运行经验,揭示风险调剂在实现医疗保障一致性目标过程中的作用。从国际经验角度初步探讨我国医疗保险风险调剂金制度的发展方向,为进一步深化医疗保障制度改革提供相应参考。

To guarantee the consistency of treatment for people covered by different insurance programs is not only an important goal pursued by countries around the world while achieving universal health coverage(UHC), but also a significant principle in the reform of the healthcare security system. This paper focuses on the formation background, application scenarios and operational experience of the health insurance risk adjustment mechanism in four developed countries, namely Germany, Switzerland, the Netherlands and the United States, in order to reveal how risk adjustment mechanism works in the process of achieving the goal of consistency in health care coverage. This paper proposes general idea about constructing China’s health insurance risk adjustment mechanism from the perspective of international experience and provides corresponding reference for deepening the reform of health insurance system in China.