本文選題：新農(nóng)合大病保險　切入點：風(fēng)險識別　出處：《山東大學(xué)》2014年碩士論文　論文類型：學(xué)位論文

【摘要】：由原來的公費醫(yī)療到全民醫(yī)保，我國醫(yī)療保障體系不斷完善和深化�，F(xiàn)階段我國基本醫(yī)療保障水平比較低，特別是對重大疾病的保障存在不足。醫(yī)療費用個人負(fù)擔(dān)重，因病致貧、因病返貧現(xiàn)象比較普遍。為了提高城鄉(xiāng)居民醫(yī)療保障水平，2012年國家發(fā)布了《關(guān)于開展城鄉(xiāng)居民大病保險工作的指導(dǎo)意見》，引入市場機(jī)制，建立大病保險制度，減輕居民的大病負(fù)擔(dān)。保險公司也以社會管理者的身份參與到我國醫(yī)療衛(wèi)生改革的浪潮中。 城鄉(xiāng)居民大病保險即將在全國鋪開實施，通過全面識別風(fēng)險因素和科學(xué)風(fēng)險評估，可以讓決策者了解現(xiàn)階段大病保險面臨的風(fēng)險狀況，還能為決策機(jī)關(guān)調(diào)整工作方式起指導(dǎo)作用，對大病保險穩(wěn)健運營有重要意義。 回顧以往文獻(xiàn)資料，前人對社會醫(yī)療保險的總結(jié)和研究多集中于基金風(fēng)險、管理模式等具體問題的探討，對運營風(fēng)險的全面識別和測算問題涉及較少，并且站在保險公司角度進(jìn)行分析，考慮的風(fēng)險因素也會有所不同。因此文章的目的在于全面識別影響保險公司運營大病保險的各項風(fēng)險因素，，形成風(fēng)險評價體系，并嘗試用風(fēng)險度量方法評價2013年試運行狀態(tài)下的新農(nóng)合大病保險風(fēng)險狀況。 在新農(nóng)合大病保險的時代背景和政策背景下，文章以全面風(fēng)險管理理論為支撐，結(jié)合山東人保2013年新農(nóng)合大病保險數(shù)據(jù)，挖掘現(xiàn)實工作和數(shù)據(jù)背后反映的問題，初步識別新農(nóng)合大病保險存在的內(nèi)部和外部風(fēng)險因素。識別出的風(fēng)險因素經(jīng)過保險公司專業(yè)人員的修正和補充，建立了風(fēng)險評價指標(biāo)體系。在風(fēng)險評估環(huán)節(jié)中，考慮到大病保險運行時間較短，具體的風(fēng)險數(shù)據(jù)難以掌握，有效數(shù)據(jù)時間跨度短也難以做回歸分析，因此本文選擇運用AHP-模糊綜合評價模型為風(fēng)險做評估。首先用層次分析法確定指標(biāo)權(quán)重，采用專家咨詢法，邀請高校保險系教授、衛(wèi)生部門、保險公司大病保險管理部門以及醫(yī)院醫(yī)保報銷部門等4個單位的12名專家對風(fēng)險因素進(jìn)行評估。隨后運用模糊綜合評價測算指標(biāo)風(fēng)險值。評價結(jié)果通過ABC法進(jìn)行分類，將指標(biāo)分成了“一般風(fēng)險因素”、“主要風(fēng)險因素”和“重要風(fēng)險因素”，結(jié)果顯示大病保險存在一定風(fēng)險，但尚在可控范圍，各指標(biāo)中“政策管理”對大病風(fēng)險影響程度最大，其次為“醫(yī)療需求風(fēng)險”和“運營管理風(fēng)險”。“基金風(fēng)險”對整體風(fēng)險影響較小。風(fēng)險控制方面，依據(jù)控制的基本步驟、結(jié)合測算結(jié)果，有針對性的為每個風(fēng)險主體提供風(fēng)險控制建議。 評價結(jié)果能幫助決策者更全面認(rèn)知大病保險存在的風(fēng)險隱患，了解目前的風(fēng)險情況，并能提供風(fēng)險控制的側(cè)重方向。只有保證基金安全、控制醫(yī)療需求、加強運營管理、科學(xué)制定大病政策，才能確保大病保險安全運行，才能讓居民更大程度的享受醫(yī)療福利。
[Abstract]:From public medical treatment to universal medical insurance, the medical security system of our country has been continuously improved and deepened. At this stage, the level of basic medical security in China is relatively low, especially in the protection of major diseases. The individual burden of medical expenses is heavy. In order to improve the level of medical security for urban and rural residents, in 2012, the State issued the guidelines on carrying out serious illness Insurance for Urban and Rural residents, introducing a market mechanism and establishing a serious illness insurance system. Insurance companies also participate in the wave of health care reform as social managers. Urban and rural residents' serious illness insurance will soon be implemented throughout the country. Through comprehensive identification of risk factors and scientific risk assessment, policy makers can understand the risk situation facing serious illness insurance at this stage. It can also play a guiding role in adjusting the working methods of the policy-making organs, and has important significance for the steady operation of the insurance against serious illness. Reviewing the previous literature, the previous summary and research on social medical insurance mainly focused on fund risk, management model and other specific issues, and the overall identification and measurement of operational risks were less involved. Therefore, the purpose of this paper is to comprehensively identify the risk factors that affect the operation of the insurance company and form a risk evaluation system. The risk measurement method is used to evaluate the risk status of New Rural Cooperative Disease Insurance (NCMS) under the condition of trial operation in 2013. Under the background of the times and policies of the New Rural Cooperative Medical Insurance (NCMS), this paper, supported by the theory of comprehensive risk management, combined with the data of PICC in 2013, excavates the problems reflected in the actual work and the data. The internal and external risk factors of NCMS insurance are preliminarily identified. The identified risk factors are revised and supplemented by insurance company professionals, and a risk evaluation index system is established. Considering the short operating time of serious illness insurance, the difficulty in mastering specific risk data, and the difficulty in regression analysis for short time span of effective data, Therefore, this paper chooses the AHP- fuzzy comprehensive evaluation model to evaluate the risk. Firstly, the AHP is used to determine the index weight, and the expert consultation method is adopted to invite the professors of the insurance department of colleges and universities and the health department. The risk factors were evaluated by 12 experts from 4 units, including the insurance management department of the insurance company for serious illness and the medical insurance reimbursement department of the hospital. Then the index risk value was measured by fuzzy comprehensive evaluation. The evaluation results were classified by ABC method. The indexes are divided into "general risk factors", "main risk factors" and "important risk factors". The results show that there is a certain risk in the insurance of serious illness, but it is still under control, and "policy management" has the greatest influence on the risk of serious illness. Secondly, "Medical demand risk" and "Operation Management risk". "Fund risk" has little effect on the overall risk. In risk control, according to the basic steps of control, combined with the calculation results, Provide risk control advice for each risk subject. The evaluation results can help the decision makers to understand the hidden risks of the insurance, understand the current risk situation, and provide the direction of risk control. Only to ensure the security of the fund, control medical needs, strengthen the operation management, Only by making the serious illness policy scientifically can we ensure the safe operation of the serious illness insurance and let the residents enjoy the medical benefits to a greater extent.
【學(xué)位授予單位】：山東大學(xué)
【學(xué)位級別】：碩士
【學(xué)位授予年份】：2014
【分類號】：F323.89;F842.684;R197.1

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