摘要
以职工医保风险因素较为典型和突出的上海市为例,构建精算模型,实证评估“门诊共济”时代职工医保基金的收支风险,并通过政策模拟,为应对风险提供建议。结果显示:职工医保基金中短期和长期风险存在差异,按现行政策,职工医保基金将在2035年前收不抵支、出现亏空;统账之间风险不同,统筹账户收支倒挂、穿底风险显著,个人账户结余过多、资金使用低效;“门诊共济”相关改革可以降低基金结构方面的风险;配合人口(激励生育、放松迁入限制)、医保支付(控费)、筹资(延迟退休、退休人口缴费)等政策,“门诊共济”相关改革能更大程度避免基金收支风险,有助于基金高效、持久运行。
An actuarial model was constructed to empirically assess the risks to the income and expenditure of the employees medical insurance fund in the era of"outpatient co-payment",taking Shanghai as an example,where the risk factors of the employees’medical insurance are typical and prominent,and to provide suggestions to cope with the risks through policy simulation.The results show that there is a difference between the short-and long-term risks of the employees’medical insurance fund,with the current policy indicating that the fund will not be able to cover its expenses and will be in deficit by 2035.The risks between the unified account and the account are different,with the risk of inversion of income and expenditure and significant risk of undercutting of the individual account,and the risk of excessive balance and inefficient use of funds.The reforms related to"outpatient co-payment"can reduce the risks in the structure of the fund.Together with policies on population(incentives for childbirth,relaxation of re strictions on migration),health insurance payments(fee control)and financing(delayed retirement,contributions from the retired population),the reforms related to"outpatient co-payment"can avoid to a greater extent the risks of income and expenditure of the fund and help the fund to operate efficiently and sustainably.
作者
沈思远
李华
SHEN Siyuan;LI Hua(Shanghai Children's Medical Center,School of Medicine,Shanghai Jiao Tong University,Shanghai 200127,China)
基金
上海财经大学2020年研究生创新基金课题资助“城镇职工基本医疗保险基金可持续性研究——以上海市为例”(CXJJ-2020-202)。
关键词
门诊共济
职工医保
风险管理
精算分析
outpatient co-payment
employee health insurance
risk management
actuarial analysis
