A Study On The Payment Of Medical Insurance By Disease

China has established the Basic Medical Insurance System for Urban Employees in 1998, the New Rural Cooperation Medical Care System( NRCMCS) in 2003 and the Basic Medical Insurance System for Urban Residents in 2007. By the end of 2015, China has basically realized Universal Health Insurance with insurance participants amounted to 1.35 billion. The reform of medical insurance system is a recognized worldwide problem, while the medical insurance expenses control is the difficulty of this problem. Medical insurance payment method is the core of medical insurance management, which concerns the protection of insurance participants’ rights and interests, balance of payment for medical insurance fund, the quality of medical service and the reasonable allocation of medical service resources.From the development courses of medical insurance development at home and abroad, we can see that every payment method has its own advantages and disadvantages, and no payment method can solve all problems in medical insurance payment management. There is no best payment method, only the most suitable one. Medical insurance institutions and medical institutions has been always in a state of “ gaming ”.This paper made a serious analysis on specific cases of payment per disease scoring implemented by Huaian City of Jiangsu Province and an intensive study on the background, institutional design, operating process, implementation effect, existing problems and other contents of this reform. This paper considered that payment per disease scoring is a combination of the principle of “ spend- and- tax, balance of payments ” of medical insurance fund, the requirement on control of total amount of payments and the weight of relative costs between different types of diseases, and accordingly explored a new type payment method of “ fixing work points ” by medical insurance, “ earning work points ” by hospitals and a two- way linking up between hospital incomes & total amount of disbursable funds and “ work points ”. This new type payment method plays a leverage effect for balancing the medical services quality and controlling expenses to a good extent and may be promoted and applied in more places. Meanwhile, this paper provides reproducible, learnable and applicable model for reform on innovative medical insurance payment method, further improves the payment method of medical insurance expenses, and puts forward constructive comments and suggestions for realizing sustainable development of medical insurance system.