Research On Financing Ratio Estimation And Medical Expenditure Payment Management Of Urban Employees' Basic Medical Insurance Fund

Urban employees'basic medical insurance system is an important part of the social medical security system in our country. The smooth efficient running of the medical insurance fund (MIF) is the key to the sustainable development of this system. Urban employees'basic medical insurance system has been put into effect in 1999 in China. After 13 years, although national MIF presents surplus, MIF's operation of districts which have different population structure, industrial structure and economic development level are very different, both surplus and deficit are common and serious. Scientific accurate income and outcome calculation closely integrated with their own characteristics is the priority of MIF's management and the fundamental guarantee of MIF's smooth efficient operation. Therefore, this paper puts into deep research from three aspects of MIF's operation -- fund raising, payment, fund management and control, and attempts to make an scientific accurate calculation and analysis for key indicators of the operation the urban employees'MIF, construct models and analyze the gaming behavior of the different subjects in the medical insurance market, and study the management and control strategies of each link if the MIF's operation. All these above hope to provide thoughts and methods for how to keep Smooth efficient operation of the medical insurance fund and theoretical and empirical references for perfection and reform of the urban employees'basic medical insurance system.Firstly, this paper hackles the related theories on medical insurance system and elaborates the research progress at home and abroad on the financing, payment and operation of the medical insurance fund. After that, it reviews and summarizes the historical and present situation of the operation of urban employees'basic medical insurance fund in China. Then, it refines the factors through empirical analysis which influences the revenue and expenditure of the urban employees'basic medical insurance fund in China.Secondly, taking X city for example, we calculate the annual financing ratio of X city through using ILO Financing Model and Kernel Density Estimation. We also forecast and analyze the balance between income and outcome of the urban employees'basic medical insurance fund through using Grey Relational Analysis Method. Studies have shown that the calculated financing ratio is 7.7% if the experienced risk multiplier takes a value of 0.13. Under present medical insurance policies, the medical insurance fund is able to operate safely and stably before 2012. However, the fund would be start facing deficit successively at the different growth rate of salary (pension) after 2012, and would be involved in deficit completely after 2016. Thirdly, from aspect of medical service provider, we calculate the national outcome of the urban employees'basic medical insurance fund through using Time Series Method and confirm exist of the physician-induced demand through Empirical research based on constructed model. From aspect of medical service demander, we make a simulated estimation for outcome of the urban employees'basic medical insurance fund in X city through using Microanalysis Simulation Model. The results shows that within five years, compensating 70 percents of hospitalization costs will save about RMB 1.1 billion than present proportion and is a better choice for X city's current situationThen, we construct game models between each two sides among hospitals, insurance institutions and patients. Through putting the data of medical insurance illegal cases in X city into the game model and taking an analysis, we found that it is a common phenomenon that the medical insurance fraud exists in X city. The key to improve efficiency of the urban employees'basic medical insurance fund is that increase punishment of the illegal fees and increase gains of insurance institutions, reduce its supervision costs.Finally, on the basis of theory and mathematical research, this paper has put forward a series of management strategy in perfecting the management of urban employees'basic medical insurance fund in our country. This paper has 15 graphs, 72 tables, 148 references.