| The implementation of the Basic Medical Insurance System related to the employees' interests, and it becomes a hot topic among various circles of the society and the broad masses of the people. The original intention of the Basic Medical Insurance System is not only ensure the employees' basic medical demand but also have good effect on controlling the medical expenditure. The intention came out on the whole at the initial stages, but as the time gong, the effect of the policy weakened. Thus, to make sure that the Basic Medical Insurance System can be carried out smoothly, the government should strengthen the study on the strategy of expenditure controlling, keep a sound hold on expenditure, and raise the efficiency of the fund utilization. There are achievements as well as problems during the four years since the Basic Medical Insurance System was carried out Dezhou. The purpose of the study is to find out how to make sure that this system can operate smoothly. By analyzing the course of the Basic Medical Insurance System and the basic situation of the situation of running, we can find out the influencing factors of hospitalization's expense which was paid by the fund supplier and the law of how it changes, then can predict the changing trend of hospitalization expense, finally, we can offer some suggestions to adjust the Basic Medical Insurance System timely, balance soundly, and operate smoothly.This article use both qualitative data and quantitative data. Firstly, we gathered all of the data related to hospitalization among insurants directly under the Dezhou city government from Jan 1st 2001 to Dec 31st 2004, including the insurants' annual consolidated fund, insurants' medical situation, comprehensive index of medical organizations, insurants' unit categories, personal information, application of consolidated fund, hospitalization expense .and how it is categorized, medical expenditure and its proportion, and the data that Dezhou government owned. All the data was coded by time, and data belonging to insurants irrelevant to the study wasfilteredThe main results of the research as below: 1.The Basic Medical Insurance Systemruns smoothly on the whole, the number of insurants is increasing year by year, theindividual account has been opened, the surplus of consolidated fund is small, thepurpose of mutual-aid has realized. However, the proportion of fund balance isdecreasing year by year.2.The hospitalization expense per capita is in increasing by year;and the number ofoutpatients floating into different levels of organization is increasing, and theoutpatient number of the first-tier hospitals is smallest, of the tertiary hospitals islargest;There is significant difference in hospitalization expense among insurants ofdifferent jobs, and the officer's expense is highest. There difference between activeworkers and retirement staff is significant, too.3.The systems of heavy medical rescue and overall arrangement are the effectivecomplementary system the Basic Medical Insurance System. The payout proportionof consolidate fund of heavy hospitalization expense is increasing by about 52.23%every year. The content that can resist the payout risk of the Basic Medical InsuranceSystem's consolidated fund is facing overspending risks.4.According to the utilization of hospitalization expense, there is significantdifference among insurants of different age groups, the expense is increasing as theinsurants are aging;the hospitalization expense per capita of retirement stall ishigher than that of active workers;The expense of officers' is highest, the publicinstitutions' is secondary, and the employees' is third.5.The changing trend of hospitalization times is obvious among different levels ofmedical organizations, units and work category. It is predicted that there will be2269 insurants visiting the first-tier hospitals, 2391 insurants visiting the secondary hospitals and 4183 insurants visiting the tertiary hospitals in 2005.There is also a obvious changing trend of hospitalization expense per capita among different medical organization, units and work category, it will be 2719yuan in the first-tier hospitals, 4123yuan in the secondary hospitals, and 7781 yuan in the tertiary hospitals. Averagely, the consolidated fund will pay 3303yuan and the individual will pay 2741 yuan for every inpatients.By the result ,we give the Conclusion and suggestions: 1 .Perfect the Basic Insurance System as soon as possible, Strengthen the supervision and management mechanism, prevent the consolidated fund from loss. The Basic Medical Insurance System directly under Dezhou city government can operate smoothly on the whole, but the number of inpatients and the hospitalization expense per capita is presenting increasing trend, the proportion of fund balance is decreasing. Some policy proposals can be made to perfect the Basic Insurance System according to the above findings: ?As far as the supplier is concerned, importance should be attached to expense controlling. The Basic Insurance System adopts the way of being paid after according to the service items, which induces unnecessary service items or quantity in order to get more compensation. As the third side of the service, the insurance organization cannot control the service course in advance, as a result it cannot prevent effectively the medical expenditure from rising. Urge hospitals to strengthen the quality construction and standardize the medical behavior. Pay attention to the medical quality and characteristic, insist on adjusting measures to the diseases, give the priority to the medicine or treatment that has positive effect and reasonable price, put an end to the behavior to supplying excessive service. Carry out the provision seriously, distinguish the basic and special medical care self-consciously.(2)It is suggested that examination, assay and other services except medicine should be classified into A and B, the equipment examination and assay of A should be brought into the overall arrangement wholly, while the equipment examination and assay of B should be brought into overall arrangement partly, the equipment examination and assay above the scope should be paid by individually absolutely, limit the proportionof irrational examination and assay. At present, both assay and examination by small equipment are not included in the overall arrangement, and the result is that their proportion is increasing, it is hard to resolve the problem that both doctors and patients get irrational interests from the insurance system. Paying the assay and examination according to the disease type may be in favor of controlling the proportion.2.Give attention to both efficiency and benefit, lead inpatients and expenditure to float rationally. ? Strengthen the checkup power on the Fixed-point hospitals, especially the secondary-tier hospitals and tertiary hospitals, limit the number of open hospitals, implement examination system on fixed-point hospitals, induct patients to go to hospitals with more reasonable charge, higher quality, better attitude and hospitals which can perform the system better. The inpatients should float to large organizations and the outpatients should float to the small organizations. It is propitious to raise the efficiency of the resource utilization, make organizations of different level do best, however, as the insurants' self-health protection is enhancing and there are obvious differences in both hardware and software among different organizations, it is natural that the insurants will choose the tertiary hospitals, as a result, the expenditure amount paid by consolidated fund will be raised;As to the hospitalization, the difference of proportion paid by individuals is not obvious among medical organizations of different levels especially between the secondary-tier and tertiary medical organizations. The difference of starting payment criterion among different organizations is not significant. The Result is that the tropism is too centralized. It is not propitious for the regional health comprehensive service to develop, or the medical organizations to develop evenly, and unfair competition will be induced, medical technology and market monopoly will be formed, and the insurance fund cannot be use rationally and effectively. Therefore, it is necessary to limit the number of the fix-point hospital, control the expense in a scientific way, induce reasonable distribution, probe the more reasonable payment way called "controlling the amount, managingthe average expense ", establish a strict assessing way to standardize the medical care, decide the deducting coefficient according to the standardization level. Probe the payment way according to the disease type.(2)Limit the use of individual account, enhance its effect in the insurance system. The individual account is managed by the insurants themselves, it make the fund of this part cannot be used to buy medicine or service. So restriction mechanism should be put on the individual account to make it be used in medical care.(3)Strengthen regional health programming, increase the efficiency of resource utilization.3. Perfect the finical and management method of the insurance fund. The Basic Medical Insurance System is a new thing in our country, and it is on the stage of being extended widely. It is noted that the amount of insurance fund is different from endowment insurance or the workers' pay. In some countries, the of the there are social insurance organizations with unsmoothing management mechanism, large scale, little harmony, many Holes, high management cost;and there are organizations that just pay attention to compete the financial amount, without knowledge of the utilization of the medical expenditure, as a result, some units' employee, just join the system as heavy medical expenditure takes place. Some insurance organizations manage the fund with lagging social method, and it is difficult for them to grasp the man-causing trend of the fund overspending, to communicate with the medical organizations, thus they make it easier for the moral hazards to come forth. Thus we provide following three recommendations: the first one is that it is necessary to establish and perfect a social insurance system with uniform system, policy, management, and the category of the insurance can be employee endowment, medical care and unemployment, at the same time, establish a team of insurance organizations with high efficiency, capability and definite right and duty, strengthen and standardized their functions, and make them operate orderly and narrowly. The second one is that: to use the amount of the employee's wage and caliber as financial base, we should make them clear according to the statistics department or relative departments' criterion. The last one is that apply thelegalized and economized management of fund pooling, implement the State Department articles about collecting fund of social insurance strictly, manage the fund pooling work with law and economic methods.4. Broaden the guaranteeing and rising value's channels of the account fund.As the individual account's interest rate is far low than the increasing index of medical expenditure, the individual account is a medical ticket whose value is reducing gradually, thus probing and finding rising value channels with low risk and keeping the account fund in the worst condition of rising value are the precondition of ensuring the fund operating evenly. Appoint the fixed-point hospital for referral within province, large and small cities to avoid the patient float freely and control the unreasonable expense decrease the individual payout proportion of the above two kind of insurants, reduce the expense difference that the individual was charged with. If the fixed-point hospital was not appointed for the referral case, the patient will choose the hospitals too freely.5.Establish risk fund to avoid risk that caused by gusty health accidents. Regarding the phenomenon of local insurants using service in other areas, gusty health accidents and so on, risk fund should be established to avoid the risk. |
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