Risk-Pooling Fund Risk Forecast And Countermeasures Research On Urban Employees' Medical Insurance In Kunming

Urban Employees' Medical Insurance is a great-covered social security course which plays an active role in enhancing medical security ability and employees' health. Based on "model of saving medical insurance" and "model of social medical insurance", medical insurance in China mainly adopts the model of "Combination of individual account and social risk-pooling fund". Whether insurance premium equals expenditure of medical services is the premise of maintaining development of system. Medical insurance continuous development. Medical insurance in Kunming commenced in April,2001 and covered more than 0.7 million of urban employees in 2004.At the Moment, the basic risk-pooling fund has showed potential risk problems, which got high attention from medical insurance organiztions. This study forecasts the tread of pooling-fund in Kunming for 5 years and explores the risk factors.Firstly, the study has constructed the microanalysis simulation model of medical insurance in Kunming which forecasts the insurance premium and expenditure for 5 years and ratio of individuals' payment to the total expenses. Microanalysis simulation model is a kind of policy analysis model with individual or family as research unit and simulates the procedure and result of socio-economic policy which plays an important role in establishing health economic policy, regional layout of health resource and analyzing the macro effect. The microanalysis model in Kunming comprises 6 primary modules, including module of new employees who participate medical insurance, module of employees who quit medical insurance, revenue module, hospitalization module, chronic module and policy module. Three aspects of work in constructing the model: 1.Designing the variables and procedure of module;2. Setting Parameters used in the model;3.Implementing random simulation by Monte Carlo method. During the course of constructing the model, one of the difficult sessions is to create model parameters used as probability values or probability distributions. Parameters' set directly decides the precision of predicted result. This study explores the method of ascertaining the distribution of continuous variables such as expenditure of hospitalization and chronic clinic. Previous study assumed that the distribution of medical expenditure was uniform distribution, the simulation result was not satisfaction. The study used the ARENA software to simulate subsections' expenditure distribution again and again,accordingly finding the most ideal distribution. The final simulated distribution: the expenditure of hospitalization is divided into 5 subsections, the concentrated subsection submits to uniform distribution, 5 other subsections submits to beta distributions. The distribution of chronic clinic is divided into 4 subsections, the middle two subsections submit to uniform distribution, whereas the other two subsections submit to beta and exponential distribution respectively. The model runs well is based on two premises: 1.The policy of medical fund raising and disbursing in 2005-2009 is the same as 2004;2.The sex distribution and age distribution of new employees in medical insurance is the same as that in 2004. The result of microanalysis model in Kunming revealed that: 1.Basic pooling-fund will face risks in the following 5 year, the gap between insurance premium and medical expenditure will become small.2.Specific pooling-fund performs well and fund income surpasses expenditure.3.Retirees' ratio of medical payment to their income increases year by year, the medical payment burden of retirees is a little higher compared to the level of their wages.Secondly, aiming at the problem of fund risk, the study explores the correlative factors by method of chain substitute analysis which substitutes each factor of complicated economic phenomenon in turn and by which makes sure the influencing degree of every one factor. The income of fund can be expressed by product of four main factors (number of Insurance employees x wage base x rate of fund collection x ratio of switching to pooling fund). The expenditure of fund can be expressed as: number of Insurance employees xrate of seeing doctors x average medical expenditure at a time x ratio of payout from pooling fund. The result revealed that: l.The government should further enhance the rate of raising fund;2.Rate of seeing doctors has become one main risk factor of fund expenditure;3. Average medical expense per patient has reduced the fund risk.Finally, the study brings forwards seven countermeasures.l.Extending the cover rate of medical insurance;2.Enhancing the proportion of raising medical insurance revenue;3.Popularizing health care education and controlling prevalence of chronic;4.Developing community medical care and promoting first and second medical institution service quality;5.Improving the payment means of "overall medical expenditure cotroll".6.Giving favor to retirees clinic expenditure thereby reducing outpatients divertinginto inpatients.ZStrenthening the financial support to patients who have economic difficulties to pay their medical treatment.