Research On Medical Insurance Rates Based On The Payment By Disease Model

With the economic development of our country and the construction of social medical security system,our health insurance business has entered a new stage of development.According to the data of the CBRC,the insurance premium of China's health insurance market has increased rapidly in recent years,and the amount of compensation is also increasing rapidly.In 2018,China's health insurance premium scale has reached 544.8 billion yuan,an increase of 24%.In the same year,China's health insurance payment expenditure reached 174.4 billion yuan,an increase of 34.7 percent over the same period last year.According to international experience,pay-for-disease mechanism can effectively control the excessive increase of medical expenses.In order to solve the problem of the rapid increase in the amount of compensation paid by commercial medical insurance,it is necessary to study the medical insurance paid by disease.At present,payment by disease is seldom used in commercial health insurance,and the main difficulty lies in the cost assessment of loss in the pricing process.In medical insurance,the cost of loss,that is,the cost of settlement,is based on the calculation of hospital medical expenses.Therefore,only by studying the distribution of hospital medical expenses can we find out the rule of loss distribution and calculate the claim cost.The main content of this paper is to fit the optimal distribution and estimate its parameters according to the characteristics of the sample data,and finally calculate its rate according to the medical insurance pricing theory.From the structure of this paper,there are six chapters.The first chapter mainly introduces the research background.At present,China's health insurance is in a period of rapid development,but the amount of medical insurance claims increases greatly,and the payment mechanism by disease type can effectively control the increase of medical expenses.It is found that there is little research on the rate of commercial medical insurance paid by disease,so this paper studies the rate paid by disease from the point of view of rate pricing.The second chapter mainly includes an overview of the payment by disease and the theoretical basis of the related medical insurance rate determination,including the definition and difference of the payment by disease mode,the pricing model of medical insurance and the method and process of rate determination.The third chapter introduces the commonly used skewness distribution model,because the medical expense data are generally skewed distribution,including Pareto distribution,lognormal distribution,gamma distribution and Gaussian mixture model,and two nonparametric estimation methods of histogram and kernel density estimation.Finally,the commonly used goodness-of-fit test method is used to observe the degree of difference between actual and expected values,including chi-square test,KS test and P-P map.The fourth and fifth chapters are the focus of this paper,and the fourth chapter is the empirical analysis,which mainly studies the distribution law of medical expenses data under the mode of payment by disease type.The fourth chapter uses the MATLAB and R software to calculate the Gaussian mixture model and the kernel density estimation model,in which the kernel density estimation method uses the Silverman empirical method to estimate the smooth parameter.By comparing the chi-square statistic with the chi-square 0.05 quantile critical value,it is found that the Gaussian mixture model has the best fitting effect on the medical cost data according to the disease payment mode.The fifth chapter is the calculation of rate pricing,according to the medical insurance pricing model commonly used in practice,to make reasonable assumptions about the pricing elements,including claim cost hypothesis,hospitalization rate hypothesis and additional rate hypothesis.At last,according to the data of each pricing factor,the model of rate determination is used to calculate the rate of medical insurance under the mode of payment by disease for different sex and age groups.The sixth chapter discusses the application of payment by disease,including the way it can be used for medical insurance payment and medical performance evaluation,but there are still some application difficulties,including the limited coverage of disease species and the inconsistent standard of calculation of medical expenses of disease species,the increase of medical risk of patients,the low enthusiasm of medical personnel and the imperfect medical quality supervision mechanism.And put forward the related suggestions to these application difficulties,including expanding the coverage of diseases,standardizing the method of calculating the cost of diseases,perfecting the training and incentive system for clinicians,supervising the quality of medical treatment,supervising whether there is prevarication or private charge in hospitals.If we can solve the above problems,we believe that the medical insurance paid by disease can be used better in the future.