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1、 硕士研究生学位论文 拉萨市医疗保险付费方式研究 The study on the medical insurance payment method of Lhasa 姓 名： 杨丽丽 指 导 教 师 ： 谢 红 院系（部所） ： 经济与管理学院 专 业： 行政管理 研 究 方 向 组织人事管理 完 成 日 期 ： 2014-05 I 摘 要 目前，我国的医疗卫生和医疗保障领域存在许多问题， “看病贵、看病难”的问题是这诸多问题中的一个突出问题，严重影响到人民群众医疗保障需求的满足。为解决这一问题，在医疗卫生领域进行了多项改革，而对基本医疗保险付费方式的改革是诸多改革中重点。通过付费方式和模式
2、的改革，可以更好的管控医疗服务机构的各种行为（重点是医疗服务行为） ，进而达到控制医疗服务成本，抑制医疗费用过分支出，最终达到缓解医保经费支付的压力，化解支付风险的目的。通过各项改革，将人民群众在看病就医时的经济损失降到最低。如今世界上存在六种主要的医疗保险付费方式，即按服务项目付费、按病种付费、总额预付、按人头付费、按单元付费和定额结算。对每种付费方式进行比较分析， 都能发现这一付费方式存在一定的优势和一定的使用范围，同时，每一种付费方式也存在不足。在实践中，基本医疗保险管理部门会根据实际情况需要，组合使用不同付费方式，形成复合式的医疗保险付费模式。 目前，在中国，覆盖全国所有公民的基本医疗
3、保险制度已基本建立，主要包括三项制度：即针对广大农村居民的新农合制度、针对城镇没有就业人口的城镇居民医保制度和针对城镇就业人口的城镇职工医保制度，三项制度基本上已经能够覆盖我国所有的人群。不过，在统一的制度体系下，具体的运行方式会有所不同，体现在医疗保险II 付费方式上，就是不同地区所具体使用的付费方式并不一模一样。近年来，多个地方进行了医疗保障制度和医疗卫生体制的改革，在这些改革中，付费方式的改革一直都是重要内容之一。在一定程度上，各个地方现行的基本医疗保险付费方式都有一定的效果， 对于费用上涨的控制、患者负担的减轻都能起到一定作用，但也有控制医疗费用与满足医疗需求之间存在矛盾、医疗保险经办
4、机构管理成本偏高、落实定点医疗服务机构内部管理不足等问题仍然需要进一步解决。 从总体上看，拉萨市基本医疗保险制度中，依然沿用按服务项目付费这种比较传统的付费方式，是一种比较简单而且单一的付费方式。 这种付费方式的使用在短期内没有影响到整个基本医疗保险体制的运行，但从长远来看，还需要调整和完善。通过综合分析国内外现行医疗保险付费方式、比较分析我国和拉萨市现行付费方式和模式，本文提出在拉萨市，有必要对现行的付费方式进行改革和完善，在改革中，首先要吸取其他地方医疗保险付费方式改革的成功经验，其次要加快城乡基本医疗保险制度的统一和整合， 三是要积极探索实行有效机制，实现定点医疗服务机构的分级分类管理，
5、最后要探索有效手段，建立健全专家谈判协商的机制。希望在西藏自治区的基本医疗保障制度的改革中，这些建议可以发挥一些积极的影响。 关键词：关键词：医疗保险，付费方式，医疗服务机构，医保经办机构 III Abstract At present, the field of health care and medical security exist many problems in our country.The issue of “expensive and difficult medical treatment” is a prominent problem in the many problem
6、s,it seriously influence to peoples health care needs.To solve this problem,carried out a number of reforms in the health field.The reform of the medical insurance payment method is the importance of many reforms.Through the reform of the payment methods and models,better able to regulate the behavi
7、or of medical service,in turn to control the cost of medical service and reduce health care costs,finally to alleviate the pressure of the health insurance funds to pay,and to resolve a risk.Through the reform,will make peoples economic losses in the hospital to a minimum.Now,there are six major med
8、ical insurance payment methods in the world.They are paid according to the service items, paid according to a per disease, prepaid according to the total amount,paid according to a per head,paid according to the unit and paid according to the fixed settlement.Compare each of these methods，we can fin
9、d it has a good side and bad side.In practical application, the basic medical insurance management department will according to the need of actual condition, use a combination of different payment methods, form a complex medical insurance payment model. IV Now, China have established the basic medic
10、al insurance system covering all citizens broadly across the country.The system contains the new rural cooperative medical care system, the basic medical insurance system for urban residents and urban employee basic medical insurance system.However, under the unified system, the medical insurance pa
11、yment method in different areas use dont agree with each other.In recent years,many places reformed in medical security system and medical and health system,In these reforms, the reform of payment method has been one of important contents.To a certain extent,the current basic medical insurance payme
12、nt method in each place has a certain effect.It can control the growth of medical costs, reduce the economic burden of patients.But,there still are some problems ,such as the contradiction between the control health care costs and meet the demand of medical,high management costs of medical insurance
13、 agency organization and lack of internal management of medical service institutions.These problems still need to be further solved. On the whole,the basic medical treatment insurance in Lhasa is still using a single method according to the service project.It is a more traditional, simple, and a sin
14、gle payment method.This method in the short term does not affect the operation of the basic medical insurance system.But in the long run,it also need to be adjusted and perfected.In this paper, based on the research of the current medical insurance payment V method at home and abroad, through compar
15、ative analysis between basic medical insurance payment method in our country and the current methods of Lhasa,put forward the main countermeasures and suggestions.In Lhasa, reforming health insurance payment methods,need to learn from experiences of the reform of medical insurance payment methods of
16、 the rest of the country, need to speed up the integration of urban and rural residents in basic medical insurance system,need to advance the basic medical insurance classified management of medical service institutions,and need to establish a basic medical insurance experts negotiation mechanism,etc.Hope these countermeasures and Suggestions on reform and perfection of
