Research On Medical Insurance Risk Adjustment Mechanism

On February 25,2020,the "Opinions on Deepening the Reform of the Medical Insurance System" issued by the Central Committee of the Communist Party of China and the State Council stated that it is necessary to "focus on solving the problem of unbalanced and insufficient development of medical insurance."The medical insurance risk adjustment mechanism is an important medical resource allocation mechanism that is widely used internationally.The core of the risk adjustment mechanism is that the fund follows the health risks/shares the same life and price.However,in China,the research on the medical insurance risk adjustment mechanism is still in its infancy.This article summarizes the medical insurance risk adjustment mechanism in detail,the research is conducted from five aspects:the origin of the risk adjustment mechanism,the conceptual function and application scope,the core elements of the risk adjustment mechanism,the risk adjustment model,and the impact and improvement of the risk adjustment mechanism.(Ⅰ)In the 1970s to the 1990s,the multi-insurer system began to explore the reform of the medical insurance system.In order to promote fair competition,a risk adjustment mechanism was introduced-based on the size of the health risks of the insured,medical funds were provided in the form of head fees Appropriation.The introduction of the risk adjustment mechanism has changed the main body of medical insurance from the traditional tripartite relationship to the four-party relationship,and the medical insurance fund has become the focus of reform,which competes in reducing the price of medical service and improving the quality and efficiency of medical service.(Ⅱ)In the multi-competitive insurer system,the financing mechanism of the risk adjustment mechanism can be divided into two types:external financing mode and internal financing mode.What the two have in common is the setting of premiums around "actuarial fair premiums equal to risk-adjusted headcounts".The focus is on the proportion of risk-adjusted premiums in total medical insurance premiums,which determines the degree to which the risk-adjustment mechanism works.(Ⅲ)The fund allocation of the risk adjustment mechanism is the focus of the risk adjustment mechanism,and its core element is the adjster.The adjster has an incentive and guiding function for the medical insurance fund.The risk adjustment model has a complex set of mechanisms and systems.Fund pooling and allocators allocate funds to health insurance funds based on a set risk adjustment model.The risk adjustment models of various countries have evolved from socio-demographic models to health-based models.(Ⅳ)Risk adjustment mechanisms play an important role in promoting equity and efficiency,but demographic risk adjustment models provide incentives for risk selection,and health-based models are restricted.In order to make up for the financial pressure caused by the risk adjustment mechanism,many countries introduced a risk sharing mechanism.Although the risk sharing has a positive effect on relieving the pressure of fund expenditure,it also reduces the incentive to efficiency,and the risk adjustment mechanism of medical insurance is stilll in keep improving.In addition,this study also systematically studied the medical insurance risk adjustment mechanism in China,and found that the resource allocation function of the medical insurance risk adjustment mechanism is of great significance to solve the current medical insurance field facing imbalance and insufficient problems.China’s medical insurance system needs to have the basic conditions of risk adjustment mechanism,and put forward suggestions from the aspects of risk adjustment financing mechanism,medical fund allocation mechanism risk adjustment model evaluation and so on.