贵州省城乡居民医保基金可持续运行能力提升研究

Improvement inthe sustainable operation capacity of medical insurance funds for urban and rural residents in Guizhou Province

目的 分析贵州省2019—2028年城乡居民医保基金的可持续运行能力,分析其存在问题并提出提升之策,为欠发达地区城乡居民医保基金降低运行风险、提升可持续运行能力提供参考借鉴和理论支撑。方法 基于贵州省2009—2018年大部分统筹地区居民医保基金收入和支出数据,采用灰色系统GM(1,1)模型对2019—2028年贵州省城乡居民医保基金收入支出及结存状况进行预测并分析原因。结果 自2019年起,6个地区的基金相继出险,3个地区基金相对稳健运行,原因在于各地的待遇攀比做法、居民健康管理意识差、不规范的诊疗行为、分级诊疗未有效实现、异地就医监管放松。结论 城乡居民医保基金总体处于不可持续性风险之下,需要加强医保慢病健康管理效能、推进支付方式改革、实行省级统筹、落实分级诊疗、强化基金监管。

Objective To analyze the sustainable development capacity of medical insurance pooling fundsfor urban and rural residents in Guizhou Province from 2019 to 2028, to put forward strategies based on the analysis of problems, so as to provide reference and theoretical support for decreasing operation risks and improving the sustainable development capacity of medical insurance funds for urban and rural residents in underdeveloped areas. Methods Based on the income and expenditure data of the residents’ medical insurance funds in most pooling areas of Guizhou Province from 2009 to 2018, this study used the GM(1,1)model to forecast the income, expenditure and balance of the residents’ medical insurance pooling funds in Guizhou Province from 2019 to 2028 and analyzed the causes. Results Since 2019, funds of 6 regions have been in danger, and those in another 3 regions are safe and operated smoothly. The causes are unrealistic income comparison, poor awareness of health management, non-standard medical behavior, ineffective implementation of hierarchical diagnosis and treatment and undemanding monitoring of non-local medical care. Conclusions Medical insurance pooling funds are generally under unsustainable risks. It is necessary to improve the health management efficiency of chronic diseases under medical insurance, advance the reform of payment modes, implement provincial-level overall planning, carry out tiered diagnosis and treatment, and strengthen fund supervision.