Research On Hospitalization Actual Compensation Ratio Measurement Of Basic Medical Insurance For Urban And Ruralresidents

Background The establishment of a sound medical security system can not only promote the harmonious development of society,but also reduce the incidence of"poverty caused by illness".Actual inpatient reimbursement rate directly reflects the level of medical security benefits of the insured,and reflects the implementation effect of urban and rural medical insurance system.The actual inpatient reimbursement rate can be effectively improved by setting reasonable initial deductible line,capping line and nominal compensation ratio.It plays an important role to make a reasonable compensation plan and scientifically calculate the actual compensation ratio to alleviate the economic burden of residents.Objective Based on the actuarial loss distribution theory,based on the analysis of the implementation status of medical insurance for urban and rural residents in a sample county of Ningxia Hui autonomous region,by calculating the loss distribution of hospitalization expenses and the expected value of the loss distribution of medical insurance in the sample county medical institutions,adjust the deductible line,capping line and nominal compensation ratio with various combination schemes to calculate the actual compensation ratio of hospitalization.Studying how to design the compensation scheme so that the actual compensation ratio can reach the target of 75%of the policy design,it provides Suggestions and references for alleviating residents’financial burden of seeking medical treatment and improving relevant policies.Methods This study uses descriptive statistical analysis to analyze the status of medical insurance in the sample county,loss distribution method was used to calculate the expected value of loss distribution of hospitalization expenses in county-level medical institutions,and MATLAB was used to calculate the expected value of loss distribution of medical insurance under different compensation schemes,so as to calculate the actual compensation ratio of compensation amount.Results1.Analysis on the implementation status of medical insurance for urban and rural residentsIn terms of insurance participation,225,100 people participated in 2015,with the largest number of people participating in first gear,accounting for 75.53%of the total number,the second gear accounting for 18.61%,and the third gear accounting for the least.In terms of financing,the total amount of financing in 2015 was 11.096 million yuan,accounting for22.80%of individual financing and 77.20%of fiscal financing,of which 59.97%was raised by the central government.Among the fund expenditures,hospitalization compensation accounted for the most,accounting for 77.90%of the total expenditure.Regarding the amount of inpatient services provided by medical institutions at all levels,the proportion of inpatient services provided by county-level medical institutions was 82.87%,but the county-level compensation expenditure accounted for 59.03%of the total inpatient compensation expenditure.2.Overall planning of hospitalization cost loss distribution of basic medical insurance for urban and rural residentsIt can be seen from the histogram of frequency distribution of hospitalization expenses that the sample data presents a skewed distribution,weibull distribution and lognormal distribution were selected to fit the loss distribution of hospitalization expenses,egression nonlinear module was used for parameter estimation.Chi-square goodness of fit test showed that the weibull distribution was better than the number normal distribution,and the expected hospital expenses E（X）was 3,256.33 yuan.3.Analysis of loss distribution of medical insurance for urban and rural residentsAccording to the medical insurance compensation scheme for the urban and rural residents in the sample counties,the appropriate distribution of medical insurance losses was selected,and it was found that it was a mixture of several medical insurance distributions.According to the expected value formula of the loss distribution of medical insurance,the expected value of the loss distribution of the first,second and third grade was measured by MATLAB as E（Y₁）2294.82 yuan,E（Y₂）2438.24 yuan and E（Y₃）2581.67 yuan,respectively.The actual compensation ratio of hospitalization under the current scheme was further measured as 68.75%,which did not meet the policy design requirements.4.Calculation of actual compensation ratio under different compensation schemesThe capping line and nominal compensation ratio unchanged,when deductible line set for 300 yuan,400 yuan,500 yuan,and the actual compensation ratio is 71.07%,68.75%,66.43%,the starting deductible line is set as 500 yuan for first gear,400 yuan for second gear and 300 yuan for third gear,the actual compensation ratio is 67.85%,four policy scheme failed to meet design goals.Keep the initial deductible line and the nominal compensation ratio unchanged,the capping line is set at 30,000 yuan,40,000 yuan and 50,000 yuan,the actual compensation ratio is basically unchanged,and the fund expenditure does not change much.The deductible line and the capping line unchanged,the nominal compensation ratio is set as 75%,85%and 95%for the first,second and third grades respectively,the actual compensation decreased to 67.01%,three levels are 80%,85%and 95%respectively,the actual compensation than the increase was 69.03%,three levels are 85%,90%and 95%respectively,the actual compensation ratio increased to 72.09%,the nominal compensation effect on actual compensation than larger than change.The setting of starting and deductible line,capping line and nominal compensation ratio is adjusted comprehensively.When the starting and deductible line of each gear is reduced to300 yuan,the current scheme of capping line remains unchanged.The nominal compensation ratio of each gear is 85%,90%and 95%respectively,and the actual compensation ratio is increased to 75.35%,reaching 75%of the policy requirements.Suggestions1.Lower the minimum deductible line2.Maintain the capping line3.Strictly implement the supervision of medical insurance reimbursement and expand the list of drugs4.To effectively improve the clinical service capacity of county-level medical institutions5.Improve medical insurance policies and strengthen publicity...