碎片化医保制度设计弊端与农民工医保模式路径选择

我国二元社会保障模式的构建思维一直影响我国保障制度的建设,导致我国医保制度建设呈现碎片化趋势,农民工医保制度也受这一传导机制影响。鉴于碎片化医保制度存在的诸多弊端和单独构建农民工医保模式存在的制度缺陷,农民工医保模式的路径选择应该是纳入现有保障制度框架。当前最关键和最紧迫的问题是提高现有医保制度统筹层级、解决三大医保制度接续以及加强农民工医保制度的配套建设。     

Implications of the Interaction Between Insurance Choice and Medical Care Demand

The gross price elasticity of demand for medical care is decomposed into two separate  observable  components: the medical care gross price elasticity of insurance choice and the cost-sharing elasticity of medical care. When consumers alter their choice of health-care plans, the price elasticity of medical care is no longer equivalent to the cost-sharing elasticity; using the latter as a proxy for the former may produce misleading results. We present conditions under which the medical care price elasticity is  positive , the case of a quasi-Giffen good, and provide a theoretical foundation for extant empirical findings of a positive medical care price elasticity of  insurance  demand.     

Why Are Managed Care Plans Less Expensive: Risk Selection,Utilization, or Reimbursement?

This article develops a new method of decomposing the cost difference between HMO and non‐HMO plans into observed risk selection, unobserved risk selection, utilization differences, and differences in provider reimbursement rates. We implement this method using a large national sample of employer‐sponsored health insurance enrollees from the Community Tracking Study Household Survey. We find no evidence that HMO plans attract a disproportionate share of low‐risk enrollees; the US$188 difference between HMO and non‐HMO medical expenditures per enrollee can be explained by the relatively low provider reimbursement rates paid by HMO plans. This indicates there may be little need for employers to risk adjust insurance premiums or otherwise restrict employee choice of plan types.     

不同收入等级农村居民基本医疗保险受益公平性研究

公平普惠是我国卫生和健康事业建设的目标,基本医疗保险是实现目标的制度保障。本文基于安德森医疗服务利用行为理论,采用三阶段随机抽样方法采集湖北省少数民族贫困县965个农村参保者的调查数据,通过收入五等分法、二元选择模型和两部分模型对基本医疗保险受益公平性进行分析。结果发现:均等化的医疗保险政策不仅实现了规则公平,实践中也提高了低收入参保者的医疗服务利用行为,即低收入组与高收入组有相似的就诊行为,且最低收入组比最高收入组还有更高的报销可能性。但是从医疗服务利用结果和疾病经济负担来看,低收入者仍然处于劣势。最低收入组和较低收入组均比最高收入组有更高的慢性病患病可能性和更差的自我健康评价,同时低收入组有着更重的疾病经济负担。此外,少数民族居民、失业者、年长者、有配偶的居民可能有更差的医疗服务利用结果。因此,中国在实现全民医保的基础上,未来还要进一步提高医保受益公平性。     

Testing Adverse Selection With Two‐Dimensional Information: Evidence From the Singapore Auto Insurance Market

This article examines adverse selection in insurance markets with two‐dimensional information: policyholders’ riskiness and degree of risk aversion. We build a theoretical model to make equilibrium predictions on competitive insurance screening. We study several variations on the pattern of information asymmetry. The outcomes range from full separation to partial separation, and complete pooling of risk types. Next, we propose a copula approach to jointly examine policyholders’ coverage choice and accident occurrence in the Singapore automobile insurance market. Furthermore, we invoke the theory to identify subgroups of policyholders for whom one may expect the risk–coverage correlation and adverse selection to arise.     

A Comparison of HMO Efficiencies as a Function of Provider Autonomy

Current debates in the insurance and public policy literatures over health care financing and cost control measures continue to focus on managed care and HMOs. The lower utilization rates found in HMOs (compared to traditional fee‐for‐service indemnity plans) have generally been attributed to the organization's incentive to eliminate all unnecessary medical services. As a consequence HMOs are often considered to be a more efficient arrangement for delivering health care. However, it is important to make a distinction between utilization and efficiency (the ratio of outcomes to resources). Few studies have investigated the effect that HMO arrangements would have on the actual efficiency of health care delivery. Because greater control over provider autonomy appears to be a recurrent theme in the literature on reform, it is important to investigate the effects these restrictions have already had within the HMO market. In this article, the efficiencies of two major classes of HMO arrangements are compared using “game‐theoretic” data envelopment analysis (DEA) models. While other studies confirm that absolute costs to insurance firms and sponsoring companies are lowered using HMOs, our empirical findings suggest that, within this framework, efficiency generally becomes worse when provider autonomy is restricted. This should give new fuel to the insurance companies providing fee‐for‐service (FFS) indemnification plans in their marketplace contentions.     

Designing a guideline-based utilization management program

Many public and private organizations are developing and publishing clinical guidelines to assist health care providers and patients in making appropriate medical decisions. Unless clinical guidelines are part of a well-designed managed care program, they have little effect on physician practice styles. This article explores integral components of an effective guideline-based utilization management program. Initial evaluation of this program suggests that, as part of a well-designed utilization management program, clinical guidelines can inform patients and physicians, and create appropriate incentives for effective health care delivery.     

Self‐Funding of Health‐Care Plans by Small Firms: Risks and Reforms

Small employers that offer health insurance have usually offered fully insured products through traditional health plans. Recently, the Patient Protection and Affordable Care Act (ACA) has created new requirements for fully insured products that will entice more small firms to fund their own health‐care benefits. However, self‐funding poses significant risks to these small firms, their employees, and state exchanges. To mitigate some of these risks within current political realities, we recommend advance disclosures—to small firms of material changes in their stop‐loss policies, and to their employees that premium subsidies are available only on ACA exchanges. We also suggest strengthening Small Business Health Options Program exchanges by broadening the availability of subsidies and building partnerships with brokers. Finally, we recommend an expanded role for brokers and third‐party administrators in helping small firms improve their choice of health‐care insurance.     

试析医疗卫生事业发展的特殊矛盾和我国医改的路径选择

市场经济条件下医疗卫生事业发展面临五大特殊矛盾。现行医疗卫生体制要解决的首要问题是体制、机制创新问题。公立医院改革和医疗保险体制改革相结合,建立以公益性医院为主题的医疗保险职能和公共医疗服务职能相结合的制度统一、全民覆盖、统筹城乡的新型公共医疗服务保险制度,构建政事分开、管办分开、医保基金管用分开的医疗卫生管理体制,是化解现行医药卫生体制蕴藏的内在矛盾,破解我国医改难题的可行的路径选择。     

Health insurance--a challenge in India

In India, indemnity health insurance started about 3 decades ago. Mediclaim was the most popular product. Indian insurers and multinational companies have not been enthusiastic about starting health insurance in spite of the availability of a good market because health insurers have historically incurred losses. Losses have been caused by poor administration. Because it is a small portion of their total businesses, insurers have never tried sincerely to improve deficiencies or taken special interest. Hospital management and medical specialists have the spirit of entrepreneurship and are prepared to learn quickly and follow managed care principles, though they are not currently practiced in India. Actuarial data from the health insurance industry is sparse, but data from alternative sources will be helpful for starting managed healthcare. In my opinion, if properly administered, a "limited" managed care product with appropriate precautions and premium levels will be successful and profitable and will compete with present indemnity products in India.     

How do low-income enrollees in the Affordable Care Act marketplaces respond to cost-sharing?

The Affordable Care Act requires insurers to offer cost-sharing reductions (CSRs) to low-income consumers on the marketplaces. We link 2013–2015 All-Payer Claims Data to 2004–2013 administrative hospital discharge data from Utah and exploit policy-driven differences in the actuarial value of CSR plans that are solely determined by income. This allows us to examine the effect of cost-sharing on medical spending among low-income individuals. We find that enrollees facing lower levels of cost-sharing have higher levels of healthcare spending, controlling for past healthcare use. We estimate demand elasticities of total health care spending among this low-income population of approximately −0.12, suggesting that demand-side price mechanisms in health insurance design work similarly for low-income and higher-income individuals. We also find that cost-sharing subsidies substantially lower out-of-pocket medical care spending, showing that the CSR program is a key mechanism for making health care affordable to low-income individuals.     

Chancen und Herausforderungen der Rückversicherung in der gesetzlichen Krankenversicherung

In 2009 a so-called morbidity orientated risk structure equalization scheme was installed for the German statutory health insurance in order to minimize structural differences between different providers with respect to revenue and expenditures. Even with this mechanism some risks to the individual health insurance providers remain. Reinsurance could be a way to mitigate these risks, but so far only very few contracts have been signed. Moreover the existing reinsurance contracts only focus on the periphery of the statutory health insurance system such as travel health insurance. In this article we therefore analyse existing risks for individual health insurance providers and evaluate their (re-)insurability. Hereafter the potential for reinsurance solutions in the German statutory health insurance itself as well as in newer forms of healthcare provision (e.g. integrated health care and managed care) is discussed. We find that reinsurance may be a reasonable solution for many of the risks in the statutory health insurance scheme. But as research in this area is very young further analysis of the nature of risks is necessary.     

医疗卫生保障满意度调查研究——以辽宁省沈阳市为例

目的:对医疗卫生保障满意度进行研究,为构建公平、可持续发展的医疗保障制度提供科学依据。方法:根据调查目的,设计一套完整的问卷,运用计算机辅助电话调查方法(CATI),抽取2300各样本进行医疗卫生满意度调查。结论:有效样本中,34.5%的居民选择满意和比较满意,44.4%的居民选择一般,21.1%的居民选择不太满意和不满意。医疗卫生保障满意度为59.4分。     

Asymmetric information in health insurance: evidence from the National Medical Expenditure Survey.

Adverse selection is perceived to be a major source of market failure in insurance markets. There is little empirical evidence on the extent of the problem. We estimate a structural model of health insurance and health care choices using data on single individuals from the NMES. A robust prediction of adverse-selection models is that riskier types buy more coverage and, on average, end up using more care. We test for unobservables linking health insurance status and health care consumption. We find no evidence of informational asymmetries.     

中国城镇居民医疗保险和新型农村合作医疗衔接路径探讨——基于湖北省武汉市的实证分析

中国城镇职工医疗保险、新型农村合作医疗和城镇居民医疗保险的建立标志着全民医保体系的确立,但是基本医疗卫生服务仍然表现出明显的城乡二元化特征。湖北省武汉市作为中部经济发展水平较高的大城市,在城市化和人口流动加快的背景下,迫切需要实现城乡医疗卫生资源的整合和基本医疗保险制度的衔接。首先实现城镇居民医疗保险和新农合衔接,进而探索城乡居民医疗保险和城镇职工医疗保险衔接,分两步走实现城乡三大医疗保险制度衔接。     

长期医疗护理保险居民参保意愿研究——来自青岛市的调查

青岛市于2012年7月推出长期医疗护理保险制度,到目前为止,制度运行虽然已经初见成效,但广大居民的认同和支持也是影响制度可持续发展的重要因素。通过对青岛居民参加长期医疗护理保险制度意愿的调查,并对回收的数据运用Logit模型进行分析后发现,在其他变量保持不变的情况下,年龄、教育程度、月收入、子女数量、对自我健康状况评估、对长期医疗护理保险的了解程度的差异等因素都对居民的参保意愿有显著影响,而性别、婚姻状况以及对政府的信任程度的差异对居民的参保意愿的影响并不显著。鉴于此,政府应该加强宣传,提高人们对于失能的风险意识和对护理保险的认同感;同时,努力提高居民收入水平,增强居民缴费能力。     

Managed Mental Health Care: Stakeholder Effects and Policy Implications

ABSTRACT: During the past several years, healthcare delivery in the United States has shifted from a primarily fee-for-service system toward managed care. Mental health care has been affected disproportionately by this trend. The existing literature on managed mental health care is abundant, but narrowly focused. The purpose of this study is to take a broader public-policy approach, considering simultaneously the effects on system stakeholders: patients, providers, employers, insurers, and society.     

Health and Mortality Delta: Assessing the Welfare Cost of Household Insurance Choice

We develop a pair of risk measures, health and mortality delta, for the universe of life and health insurance products. A life‐cycle model of insurance choice simplifies to replicating the optimal health and mortality delta through a portfolio of insurance products. We estimate the model to explain the observed variation in health and mortality delta implied by the ownership of life insurance, annuities including private pensions, and long‐term care insurance in the Health and Retirement Study. For the median household aged 51 to 57, the lifetime welfare cost of market incompleteness and suboptimal choice is 3.2% of total wealth.     

城镇职工退休人员缴纳医疗保险费的可行性及其相关问题探讨——社会保障学者专题讨论综述

2016年初有政府官员提出要建立合理分担、可持续的医保筹资机制,合理强化医保个人缴费责任,研究实行职工医保退休人员缴费政策。部分社会保障学者在微信平台上进行了"退休人员缴纳医疗保险费是否缓解医疗基金支付压力的良方"专题讨论。讨论从退休人员缴纳医保费问题的可行性开始,逐渐深入到医疗控费、公立医院改革、政府角色定位和长期护理保险等医疗领域重难点问题。