基本医疗服务与基本医疗保险制度相协同的法治化路径

我国基本医疗保险基金主要用于保障公民的基本医疗服务。基本医疗服务与基本医疗保险制度之间呈现法律法规不协同、参保人权益和医疗服务需求方权益保障脱节、基本医保标准和服务供给内容不统一、财政支持权力分散以及基本医保个人账户阻碍基本医疗服务发展的现实困境。要使基本医疗服务与基本医疗保险制度有效协同,应当制定“基本医疗保险实施条例”,实现制度之间相衔接。每年基本医疗服务供给内容应当经过人代会审议,从而保障参保人和服务需求方的知情权、参与权、决策权、监督权。中央政府应当上收基本医疗保险基金的筹集权,确保筹资标准的统一性,实现基本医疗服务供给的均衡性。要加大对基层医疗机构的财政支持力度,保障基本医疗服务供给的公平性。逐步取消基本医疗保险个人账户制度,发挥基本医疗保险基金共济互助作用。     

法国相互健康保险:行业团结的实现路径及启示——以MGEN为例

法国多层次保障体系行业特征明显,造成社会保险碎片化严重,却有利于第二层次中相互制健康险的发展。MGEN是法国最具影响力的相互制健康险机构,通过一系列措施增进了行业团结,在第二支柱补充医疗保险中扮演重要角色。它既满足会员的共同利益、又关注个性化需求;既坚持传统的会员共同治理,又引入了市场化的现代管理方式;既保持高再分配水平,又积极参与资本市场投资;既培育团结互济的社会文化,又受到专门立法的引导与制约。当下中国的相互保险机构刚刚落地,借鉴MGEN的成功经验,包括培养互助文化、立法先行、遵从成员利益等,对中国相互保险的健康发展具有现实意义。     

闯入“禁区”大胆尝试——福鼎县开办住院医疗保险定点共保

<正>住院医疗保险是以保险方式,对被保险人因疾病住院所付医疗费给予经济补偿。住院医疗的保险化是探索医疗制度改革的一项重要内容,是符合我国的实际情况。保险如何为医疗制度改革提供配套服务呢?自1991年8月以来,福鼎县保险公司大胆求新不断探索,根据福建省保险公司制定的《简易人身保险附加住院医疗保险条款》,在县卫生局、县医院的共同配合下,迈出了与医疗单位共保尝试的第一步,在福建省率先开办了该项住院医疗保险业务。至1991年底短短四个月时间承保了6224人,保费收入约19万元。(因保险条款规定承保生效后180天,保险人才负保险责任,所以1991年未发生给付)。该项业务的开办,产生了良好的社会效果,引起了上级卫生部门和保险公司的关注。其主要做法和经验是:     

美国牙科保险制度和口腔卫生服务

世界各国的医疗保险制度五花八门各不相同。美国在发达国家中处于一种独特的位置,其原因在于它没有一个国家医疗保险体系。美国的医疗保险则是保险公司的一统天下,完全市场化了。美国的商业医疗保险种类繁多。口腔医疗保险体系是整个社会医疗保险的一个重要组成部分。但是,由于口腔医疗是在时间、方法、价格上具有可选择性的独特性医疗,在欧美等一些发达国家,对口腔医疗保险都有着特殊的规定,区别与普通的医疗保险。在国外有很多保险提供牙科保险,按治疗的不同又分为全额理赔和一定比例理赔不等。这在相当程度上控制了牙科的消费额,同时又为投保人提供了基本的牙科检查和保健,使得很多口腔疾病在发病初期得到有效的诊治。本文将重点介绍美国家的牙科保险制度和口腔卫生服务。     

北京市总工会、北京市劳动和社会保障局关于进一步组织职工参加住院医疗互助保障计划的实施意见

近年来,为了保障职工的基本医疗需求,完善社会保障制度,促进经济发展,我市不断深入推进城镇职工医疗保险制度改革,逐步建立了基本养老保险、基本医疗保险、工伤保险、生育保险、失业保险和“一老一小”、城镇无业居民等项基本医疗保险制度,形成了基本保障、广泛覆盖、保障制度规范化、管理服务社会化的医疗社会保险体系。     

英国牙医保险制度和口腔卫生服务

口腔医疗保险体系是整个社会，医疗保险的一个重要组成部分。但是，由于口腔医疗是在时间、方法、价格上具有可选择性的独特性医疗，欧美等一些发达国家对口腔医疗保险都有着特殊的规定，区别于普通的医疗保险。在国外有很多保险提供牙科保险，按治疗的不同又分为全额理赔和一定比例理赔不等。这在相当程度上控制了牙科的消费额，同时又为投保人提供了基本的牙科检查和保健，使得很多口腔疾病在发病初期得到有效的诊治。国内的医保也对牙科有某种程度的保险，但尚未有保险公司经营牙科保险的业务。本文将有代表性地介绍英国的口腔医疗保险制度和口腔卫生服务。     

农民工的实际医疗服务可及性——基于北京市农民工的专项调研

基于2011年北京市农民工专项调研数据,从医疗服务可及性角度评估了不同医疗保险对农民工的实际保障作用。结果显示,一方面,城市的医疗保险提高了农民工的预防性医疗服务可及性,但新农合未能有效发挥作用;另一方面,城市的医疗保险和新农合都未能有效促进农民工的常规性医疗服务利用。究其原因,发现医疗费用垫付和异地报销制度是降低农民工常规性医疗服务可及性的主要原因,医疗费用不需要垫付或不需要回乡报销的医疗保险才能有效促进农民工在生病后选择医疗机构就医,同时降低自我医疗的可能性。     

构筑职工医疗互助平台 发展职工互助互济活动

职工医疗互助活动是工会牵头、群众参与的利民、利会、利国的活动,是对职工基本医疗保险制度的有效补充。通过医疗互助活动,给予低收入困难职工和因病致贫人群必要的帮助。开展好职工医疗互助活动,有利于企业的改革发展和职工队伍的和谐稳定。     

互助保险机制在长期护理保障中的应用:典型案例的政策设计及绩效

自长期护理保险政策试点启动以来,部分地区以互助保险为基础架构的长期护理保险制度,在制度框架、筹资机制、支付范围、服务提供方式等方面均具有一定的创新性。基于北京市海淀区试点政策的评估表明,以自愿参保、同质群体风险分摊和收益分享为前提的互助保险机制不能兼顾保障公平性、可持续性和可负担性等多重目标。应坚持以社会保险为基础构建多层次长期护理保障体系,支持商业健康保险公司提供多层次、补充性的保险产品。同时,要做好医疗、养老服务体系的改革和衔接,充分发挥护理保险基金的保障功能和保障潜力。     

对城镇职工医疗保险制度改革中定点医疗机构管理的思考

定点医疗制度是在医疗保险管理系统中采用的对医疗服务供方进行管理的一项基本制度,其完善与否直接关系到医疗保险制度改革的顺利进行,关系着社会主义市场经济体制的完善进程。鉴于定点医疗机构管理的重要意义,本文首先介绍了各类医疗保障制度下的定点医疗机构管理的现状及存在的问题,分析了各地区医疗保险改革中的定点医疗机构管理方式,并在此基础上提出了加强对定点医疗机构管理的政策建议,以形成整个医疗保险管理系统的良性循环。     

The effect of organizational structure on efficiency: Evidence from the Spanish insurance industry

This paper provides new information on the effects of organizational structure on efficiency by analyzing Spanish stock and mutual insurers over the period 1989–1997. We test the efficient structure hypothesis, which predicts that the market will sort organizational forms into market segments where they have comparative advantages, and the expense preference hypothesis, which predicts that mutuals will be less efficient than stocks. Technical, cost, and revenue frontiers are estimated using data envelopment analysis. The results indicate that stocks and mutuals are operating on separate production, cost, and revenue frontiers and thus represent distinct technologies. In cost and revenue efficiency, stocks of all sizes dominate mutuals in the production of stock output vectors, and smaller mutuals dominate stocks in the production of mutual output vectors. Larger mutuals are neither dominated by nor dominant over stocks in the cost and revenue comparisons. Thus, large mutuals appear to be vulnerable to competition from stock insurers in Spain. Overall, the results are consistent with the efficient structure hypothesis but are generally not consistent with the expense preference hypothesis.     

An Exploratory Analysis of Insurer Groups

Grouping is a widespread and interesting phenomenon of the insurance industry, among both life‐health insurers and property‐liability insurers. Recognizing the potentially important implications of group membership for insurer behavior and characteristics, numerous academic researchers using insurance company data have included a dummy variable in their regression analysis to control for group membership. However, it has never been clear exactly what is being controlled for when such a variable is included. This article attempts to shed light on this question. Results indicate that group affiliated insurers tend to be larger than unaffiliated insurers, are more likely to be licensed in New York, are more likely to be stock firms than mutuals, and are likely to be less geographically concentrated.     

Pure Versus Mutual Health Insurance: Evidence From Swedish Historical Data

Using data from voluntary Swedish health insurance societies 1902‐1910, this article analyzes the coexistence of pure and mutual insurance societies where pure societies are characterized by charging ex ante premiums only while mutuals in addition charge ex post assessments. On average, mutual insurance societies are found to be larger and to offer greater insurance coverage per member. Pure insurance societies have, on average, higher insurance coverage per day, greater mean levels of moral hazard controls, a higher mean number of policy categories, and greater longevity.     

医保制度改革：从城镇保障到城乡统筹——医疗保障“马鞍山模式”研究

安徽省马鞍山市医疗保险制度改革，一直以其创新性和样本性被各级政府、媒体及公众广为关注，被称为“医疗保险马鞍山模式”。本文通过对马鞍山医保制度改革从城镇保障发展到城乡统筹过程的调查，介绍该市医疗保险制度的发展历程，总结、分析统筹城乡医保制度的主要内容、特点及成效，探究存在问题及对策，以期为研究中国当前的医疗保险制度改革提供参考，为广大中西部地区中小型城市的医疗保险工作提供借鉴。     

Efficiency in the international insurance industry: A cross-country comparison

The purpose of this paper is to provide new empirical evidence on frontier efficiency measurement in the international insurance industry, a topic of great interest in the academic literature during the last several years. A broad efficiency comparison of 6462 insurers from 36 countries is conducted. Different methodologies, countries, organizational forms, and company sizes are compared, considering life and non-life insurers. We find a steady technical and cost efficiency growth in international insurance markets from 2002 to 2006, with large differences across countries. Denmark and Japan have the highest average efficiency, whereas the Philippines is the least efficient. Regarding organizational form, the results are not consistent with the expense preference hypothesis, which claims that mutuals should be less efficient than stocks due to higher agency costs. Only minor variations are found when comparing different frontier efficiency methodologies (data envelopment analysis, stochastic frontier analysis).     

Effects of Corporate Diversification: Evidence From the Property–Liability Insurance Industry

Using a sample of property–liability insurers over the period 1995–2004, we develop and test a model that explains performance as a function of line‐of‐business diversification and other correlates. Our results indicate that undiversified insurers consistently outperform diversified insurers. In terms of accounting performance, we find a diversification penalty of at least 1 percent of return on assets or 2 percent of return on equity. These findings are robust to corrections for potential endogeneity bias, alternative risk measures, alternative diversification measures, and an alternative estimation technique. Using a market‐based performance measure (Tobin's Q) we find that the market applies a significant discount to diversified insurers. The existence of a diversification penalty (and diversification discount) provides strong support for the strategic focus hypothesis. We also find that insurance groups underperform unaffiliated insurers and that stock insurers outperform mutuals.     

政府购买医疗保障服务政策下商业健康保险的盈利模式

新医改提出政府向商业健康保险公司购买医疗保障管理服务的思路,为私营医疗保险市场的进一步发展提供了政策支持。但医改方案公布后,除人保健康进入这一市场外,其他公司仍举旗观望,提供该类服务的公司寥寥无几。这一困境出现的原因是保险机构对政府购买经办服务政策下,相关产品组合的盈利模式缺乏认识。对可得的有限数据进行分析,期望总结中...     

Communicating the economic value of customer ownership in insurance: A qualitative analysis of annual reports

Its distinctive ownership base leads to a customer‐owned mutual insurer representing a mission and purpose of existence that are very different from those of an investor‐owned insurer. While the owner value of the latter can be defined in terms of return on invested capital, in mutuals, the attention is shifted toward benefits and value for customers. Despite this major difference, scholars know little about mutual insurers' value‐creating processes. To begin filling this knowledge gap, the article explores and identifies how managers of mutual insurance companies understand and communicate the economic value of ownership to their customer–owners and other stakeholders. It reports on thematic analysis of annual reports of 18 mutuals, based in seven countries (England, Finland, Ireland, The Netherlands, Sweden, Switzerland, and the United States), on the basis of which the authors offer a tentative framework for enhancing scholars' and practitioners' understanding of how the economic value of ownership is understood in a customer‐owned mutual insurance company.     

医疗保障与老年医疗消费的实证分析

老年人的生活质量与医疗保障密切相关.本文运用Logistics回归和两步估计样本选择模型考察了医疗保险对老人医疗消费的影响.结果显示医疗保险能增加老年人的医疗利用水平但未能减轻医疗支出水平;人口禀赋因素是影响老年人购买商业医疗保险的决定因素,并通过交互作用影响老人的消费行为;老人医疗消费的健康效应强于收入效应.在实践中应首先从制度安排上为医疗保险提供明确的政策信号其次应为商业医疗保险的发展创造有利条件;最后应为老人营造温馨的氛围,从而减少医疗消费.     

Ökonomische Überlegungen zur Rationierung im Gesundheitswesen

This contribution first recalls the fact that binding budgets imposed by policy makers induce rationing, which in its turn by superseding the price mechanism causes inefficiencies in the market for medical services. In addition, inefficiencies spill over into the market for health insurance providing in-kind benefits, while possibly benefiting reimbursement health insurance. But then, the commodity ‘rationing’ itself has a market; indeed, the mere existence of health insurance creates demand for rationing that even increases over time. The contribution concludes with a listing of instruments at the disposal of health insurers designed to make the insured opt for policies with self-limitation features. Thus, insurers can help to reduce that demand for rationing and the inefficiencies that come with it.