| [Objectives]In the context of ageing in China,this research combines theory and practice to firstly explore the risks of current basic medical insurance of urban workers.Moreover,a theoretical model is to be developed to analyze the health service utilizations of retired workers.In addition,this research will provide a comprehensive understanding of government,medical insurance sectors as well as the retired workers.By analyzing the interrelationship among these factors,a numerical model will be developed to present the appropriate pay-in level for basic medical insurance of urban workers.Finally,solutions and recommendations will be discussed.[Methods]A systematic literature review is conducted to analyze the calculations of medical insurance,health services and related health insurance.Key notions of this research such as retirement,ageing and risks are defined.Data is collected from Human Resource and Social Security sectors,health sectors,government statistics sectors,social welfare sectors as well as risk management literatures.A framework of risk evaluation is developed.According to construction method of Interpretive Structural Model,this research sampled 10 medical insurance related specialists and academics,which forms an ISM specialist group.Three rounds of consulting events were held in forms of email communication,face-to-face interview,telephone interview as well as specialist consulting forms.A wide range of risk factors for medical insurance of urban workers are summarized.Three cities in H province were selected for the field work.By collecting 5 years of data of medical insurance funding(2012-2016),265426 medical insurance utilization cases and 600 questionnaires completed by retired workers were collected.Information such as local social-economic status,health service status,etc.was acquired.[Results]This research understands the social context of medical insurance system.The ageing in China and its impact on medical insurance system is discussed.Firstly,population ageing has changed the structure of the insured,the retirement ratio keep decline each year.Secondly,population ageing has significantly increased the expenditure of the funds.Besides,this research analyze the status of the current medical insurance system and how it operates.Unlike commercial insurance,medical insurance emphasis more on equity and coverage rather than profitability,which also suffers from limited funding sources.When health cost rapidly increase or moral hazard involves,the total fund expenditure will be significantly affected.In addition,this research establishes the model of risk in medical insurance of urban workers.The 14 factors that influence risks are categorized in 4 tiers,of which,the most direct risk factors are health service utilization and the number of insured.Meanwhile,the most influential factors are the policy of 'retired free-of-fee',the basic amount of insurance fee and the change of lifestyle.Moreover,this research explores the appropriate amount of insurance fee by setting up a numeric model.The model is developed based on the factors derived from both macro and micro level factors,which is suitable for current eco-societal status.Single system insurance fee ratio is 5.31%and multiple system insurance fee ratio is 1.29%.Lastly,this research raises policy set for development of medical insurance for urban workers,in the context of ageing China.Policy recommendations focus on three aspects,namely,the top-level design of social security policy,the management of the funds and the trend of insurance industry.[Conclusions]The risks of medical insurance for urban workers are consisted of policy system risks and natural risks.In the context of population ageing in China,the whole social security system is at stake because of a number of social-economic factors.In order to control the risks of medical insurance for urban workers,solutions should be focused on funding source and payments.This research suggests the government should take responsibility and enforce specific laws on this issue.Besides,a range of recommendations are raised such as broadening the funding channels,enhance insurance levels,supplement other forms of insurance,develop commercial health insurance,etc.[Innovation and deficiency]Under the background of population aging in China,it is of great urgency and practical significance to explore the sustainable development strategy of basic medical insurance.Compared with the current research on the issue of the payment of retirees,this study estimates the level of contribution of retirees based on the risk factors and the conceptual model.Put aside a single risk link,the main research limitations of individual behavior.From the macro and micro levels to design of the level of contribution and payment rates.The interpretative structure model is applied in the analysis of the basic medical insurance risk,system risk stratification of complex factors,explore the risk between the level and the relationship between them,to facilitate the identification and evaluation of managers and risk management.In the process of actual modeling and calculation,we explore the obstacles in the implementation,and put forward some strategic suggestions.At the same time,in the process of empirical research,only the region with the average level of the country as the object of investigation,in order to reflect the overall level of the basic medical insurance for urban workers in china.The scope of the investigation needs to be further expanded.In the conceptual model building,it is necessary to further study on how to adjust the model and how to verify the model.The researchers determined the financing retirement payment model is a suitable range of the theoretical value,can further explore the different influence on the level of financing fund operation in a follow-up study,as well as for retirees financing this one how to establish a scientific and reasonable financing channels.So as to further improve the basic medical security system. |
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