Research On The Reverse Aid Phenomenon In Social Medical Insurance

1.Research SignificancesOne of the important functions of social medical insurance is the transfer for social wealth, As wealth by the rich transfers to the poor, it is called Mutual-aid. In the condition of the social medical insurance, social wealth doesn't transfer from the rich to the poor, on the contrary way From the poor into the rich, This indicated that the design of the social medical insurance system have some problems, which we called the reverse aid.The reverse aid phenomenon exists commonly in the social medical insurance all over the world, but to different extents. In preliminary studies The research group have found obvious reverse aid phenomenon in New-type Rural Cooperative Medical System, the similar findings also have been found in the basic medical insurance system for urban employees, For instance, the suburban district in Shanghai always complains that they pay more fees and receive less compensation than the urban District. This kind of phenomenon is easily perceived by people with insurance, and directly affects the enthusiasm of the poor, threats the sustainability of this system. The research on the formation reason and alleviate method of this phenomenon is extremely important.2. Research Objectives and ContentsThis research aimed to explain the formation reason of reverse aid phenomenon by building model, and accordingly put forward some suggestions to alleviate the phenomenon.Research contents includes:(1) based on system dynamics theory, A system dynamics model of social medical insurance was built to analysis the feedback among social medical insurance system elements and reveal the formation reason of reverse aid phenomenon. (2)A finance-compensation-result related change mathematical model was build and formed a software, to simulate the Medical cost compensation and reverse aid results of sample population with different finance-compensation patterns.(3)According to the results of Continuous adjusted finance-compensation patterns, we verified the effective schemes to eliminate or alleviate the phenomenon. During the researching process, we developed some correspondingly key technologies for the following questions:How to get a large sample population for simulation research; How to build the finance-compensation-result related change mathematical model; How to make software by mathematical model, etc.3.Research Methods(1)Literature induction. With the research topic of reverse aid, we reviewed 124 journal papers and various statistical data, policy documents and related books, which provide the theoretical foundation and methodological basis.(2)Focus group discussion. We invited experts from university, research institute, health administration, medical insurance, hospitals and other departments or agencies to discussed the Abstraction expression of social medical insurance and elements, influence factors, results and expression indexes of medical insurance scheme.(3)household survey. Qualitative data which reflect the reality are obtained through household survey. In order to know the security effect and actual gains and losses from the demand-side, we investigated 2388 families,9073 residents in Shanghai Jiading District and 2461 families,7931 residents in Songjiang District.(4)System dynamics theory. The social medical insurance system model was built by Vensim system dynamics software, described internal components and the feedback of social medical insurance system elements.(5)Computer software simulation. In this research, sample population generator and medical insurance mathematical model both are the application of computer simulation technology. Through the simulation, experimental data can be quickly obtained and Large amount costs caused by household survey and policies pilot will be save.4.Research Results(1)The formation reason of reverse aid phenomenon. Reverse aid is rooted in the gap of wealth and ability to pay. As ability to pay is limited, the poor get the limited health care and medical insurance compensation. The rich have the higher economic capacity to pay, so they can afford high-cost health care and get more compensation. At this point, if the medical insurance scheme has the following three features, the reverse aid phenomenon will be accentuated:①The poor have worse accessibility of high-quality and high-cost health care;②The financing level among different income groups are closed③In the progressive medical insurance scheme, the more one costs, the more one repays. Thus, reverse aid phenomenon is closely related to the wealth gap, regional differences of health care and medical insurance finance-compensation scheme.(2)Sample population generator. Sample population data is the foundation for building medical insurance model and simulating and the indispensable links between medical insurance finance-compensation scheme and results. Based on literatures demonstration, model and simulation, Two simulation technology—Monte Carlo Methods and Bootstrap have been explored, The results show Bootstrap is more Convenient and more consistency which can provide supporting data for simulation as the sample population generator. Using the database from high-quality household survey, we made sample populations which have the same characteristics with the actual population. This method can simplify the data generation process, control and expand sample size.(3)A finance-compensation-result related change mathematical model and the software. The basic approach of building medical insurance mathematical model is: first, identify the model elements which include risk pooling, financing, pay line, ceiling line and compensation. Then identify functions among the model elements, such as income changes in the process of financing, health care cost and medical insurance compensation, finally, identify the model constraints which include keep balance of medical insurance fund, limit the suitable funding level, etc. Under this guidance, the mathematical model was formed a software by using built-in functions and macro modules in Excel software. The interface contains four parts:At the top left is moderator variables, at bottom left is medical insurance compensation scheme table, at top right is result indicators, at bottom right is cartogram which reflects disposable income and ability to pay. There are three result indicators:medical insurance fund balance rate, ability to pay and odds ratio.(4)Medical insurance scheme simulation results based on reverse aid phenomenon.①The lower the medical insurance financing level, the less compensation, and the reverse aid phenomenon is more distinct;②In quota financing scheme, the reverse aid is obvious while fusiform compensation scheme could relieve the phenomenon in the certain extent;③when financing level increased to 70 percent of health care costs, compensation schemes have no obvious effects on the reverse aid phenomenon;④proportional financing scheme is more effective than quota financing scheme in alleviating the reverse aid phenomenon.⑤different medical insurance systems for different income groups is an effective way to alleviate the reverse aid, which suggest that universal coverage of social medical insurance system for all residents should be consider carefully.⑥the security degree and shake off poverty rate increase with the financing level, the rich get more compensation than the poor.