医保省级统筹的现状、问题与建议——基于政策文本分析

Current Situation,Problems and Prospects of Provincial-level Pooling of Basic Medical Insurance——Based on Policy Text Analysis

推进基本医保省级统筹是提高医保基金风险抵抗能力与共济能力的重要举措。基于全国已实现医保省级统筹省份的政策文本,本文从统筹模式、基金筹集、基金拨付、风险责任共担和绩效考核制度等多个方面分析了省级统筹的现状,并在此基础上探讨省级统筹中的问题和未来发展思路。研究发现,不同省份的基本医保省级统筹实践在多个方面均存在显著差异;提高统筹层次有助于促进医保待遇均衡、打破就医限制,但省级统筹中存在的问题不利于统筹政策的执行与统筹目标的实现。未来应合理把握统筹政策的实施条件,促进统筹政策与经办体系统一,借鉴国际经验完善风险调整机制,协同推进统筹层次提升和配套措施改革。

Promoting provincial-level pooling of basic medical insurance is an important measure to improve the risk resistance and mutual aid of medical insurance funds.Based on the policy text of the provinces that have realized the pooling of basic medical insurance at the provincial level,this paper analyzes the current situation of the pooling at the provincial level from the pooling mode,fund raising,fund allocation,risk and responsibility sharing and performance appraisal mechanism,and discusses the problems and prospects of the pooling at the provincial level on this basis.The results show that the provincial-level pooling practice of basic medical insurance in different provinces had significant differences in many aspects.Improving the pooling level is helpful to promote the balanced medical insurance benefits and break the restrictions on medical treatment,but the problems of provincial-level pooling are not conducive to the implementation of pooling policies and the realization of pooling objectives.We should reasonably evaluate the implementation conditions of pooling policies,promote the unification of pooling policies and claim management and fund administration systems,learn from international experience to improve the risk adjustment mechanism and coordinate the reform of supporting measures to enhance the level of pooling.