吉林省医疗保险城乡一体化的可行性研究 目的，通过对吉林省医保体系的历史发展和现状进行调查、分析，结合吉林省的 实际情况，参考国际上的先进经验和国内其它省市试点的经验，探索适合我省实 际情况的医保城乡统筹的机制。 方法，本研究通过文献研究法、访谈法等方法对吉林省医疗保险体系现状进行调 查研究，采用描述性分析、秩和检验等统计方法对肺癌患者数据、2007-2012 年 吉林省新农合患者在不同级别医疗机构就医的数据进行处理，采取文献研究法和 非结构型访谈法对长春市朝阳区的试点情况进行研究。 结果，城镇职工医疗保险的各方面待遇远高于其它医保。城镇居民医疗保险和新 农合在总费用、住院天数、自费费用、自费比例、报销费用、报销比例等方面比 较接近，无显著差异。城乡统筹试点的朝阳区为新农合患者的医疗与报销提供了 方便，但是降低了患者的待遇。2007-2012 年，吉林省新农合患者在各级医疗机 构就医时，住院次均费用、住院次均自费费用、补偿比例逐年提升。在基层医疗 机构就医的患者逐年减少，到县级及县级以上医疗机构就医的患者逐年增多。基 层医疗机构在医保基金中所占的份额逐年递减，县级医疗机构所占份额逐年上 升，县以上医疗机构所占份额基本保持不变。 结论，实施医保城乡统筹，可以解决省内流动人口医保关系的转移接续问题；可 以缩短城乡差距，体现公共服务均等化的理念；可以加强对医保基金的监管和对 骗保行为的打击力度；可以扩大省内各统筹地区的医保基金规模。 关键词， 医疗保险,城乡统筹,新医改II Abstract Feasibility research about medical insurance overall urban-rural development for Jilin Province Objective，Through the study of historical development and current situation of Jilin Province’s medical insurance system, combined with the actual situation of Jilin Province, we try to build up a system for medical insurance overall urban-rural development suitable for Jilin Province. Methods: By literature review、questionnaire、logical analysis、comprehensive thinking ，we do a research on the current situation of medical insurance system in Jilin Province. Then we use the statistical methods of descriptive analysis, rank sum test, data processing and use the methods of literature study and unstructured interviews to study the pilot of Changchun City in Chaoyang District. Results: Health insurance benefits for urban workers is much higher than other health insurance, so now they can’t be merged. While urban residents and the new rural cooperative medical insurance are similar in the total costs, length of stay, pocket costs, at their own expense and reimbursement costs, reimbursement and other terms, so they can be merged. Chaoyang District provide a convenient for the majority of patients t, but reduce the patient’s treatment. From 2007 to 2012, the patient's hospitalization expenses, hospitalization times are pocket costs, compensation ratio has increased year by year. Patients in the basic medical institutions have reduced year by year, while patients to medical institutions above the county level and county-level medical treatment have increased year by year. Primary health care institutions in the health insurance fund's share gradually decline, the share of county-level medical institutions increased year by year, the share of medical institutions above the county remained basically unchanged. Conclusion: Medical insurance unified can solve the problem of floating populationIII and narrow the gap between urban and rural area ; can enhance the health insurance fund supervision and enlarge the scale of medical insurance. Keywords， medical insurance , overall urban-rural development , the new health reformI 目 录 第 1 章 绪论 ...............................................................................................................1 1.1 研究背景............................................................................................................1 1.2 国内外现状研究................................................................................................3 1.2.1 中国医疗保险体系的发展历程.................................................................3 1.2.2 吉林省医疗保险体系的发展历程.............................................................4 1.2.3 吉林省医保体系存在的问题.....................................................................6 1.2.4 国外经验................................................................................................... 11 1.2.5 国内经验...................................................................................................13 1.3 研究意义..........................................................................................................14 第 2 章 资料与方法 .................................................................................................16 2.1 研究对象..........................................................................................................16 2.2 资料来源..........................................................................................................16 2.3 研究内容..........................................................................................................17 2.4 研究方法..........................................................................................................17 2.5 质量控制..........................................................................................................17 第 3 章 结果 .............................................................................................................18 3.1 不同医保类型患者的住院总费用比较..........................................................18 3.2 不同医保类型患者的住院天数比较..............................................................18 3.3 不同医保类型患者的自费费用及自费比例比较..........................................19 3.4 不同医保类型患者的报销金额及报销比例比较..........................................19 3.5 吉林省医保城乡统筹试点现状及存在的问题..............................................20 3.6 2007-2012 年吉林省新农合患者在不同级别医疗机构就医的情况比较....21 第 4 章 讨论 .............................................................................................................24 4.1 不同医保类型患者各方面对比分析..............................................................24 II 4.2 吉林省医保城乡统筹试点情况综合分析......................................................27 4.3 加大对农村基层医疗机构的投入..................................................................28 4.4 吉林省医保城乡统筹制度设计......................................................................29 4.4.1 实施方式...................................................................................................29 4.4.2 制度设计...................................................................................................30 第 5 章 建议 .............................................................................................................31 5.1 加快制定社会保险法细则..............................................................................31 5.2 做好门诊统筹工作..........................................................................................31 5.3 完善医保支付方式体系..................................................................................32 5.4 加大对老年人医疗保障的投入力度..............................................................33 5.5 加大对预防的投入..........................................................................................34 5.6 加强三医联动..................................................................................................34 第 6 章 结论 .............................................................................................................36