我国城镇居民医疗保险基金运行的统计研究--以福州市为例

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摘要

城镇居民基本医疗保险于 2007 年 7 月开始试点实施，主要保障未被城镇职

工基本医疗保险和新型农村合作医疗保险覆盖的城镇非从业居民，是我国医疗保

障体系的重要组成部分，是我国走向全民医保的必然步骤。自启动试点以来，城

镇居民基本医疗保险虽然成效颇丰，但是由于缺乏量化指标体系和激励措施，使

其进一步的发展、实施受到阻碍，看病难、看病贵、医疗费用增长过快的现象仍

然存在。这一难点已成为学术界研究的前沿问题。

本文就上述问题，以首批试点的福州市为例展开剖析，以期对我国城镇居民

基本医疗保险的进一步实施提供可行的建议。本文首选分步论述了逐渐覆盖全民

的医疗保险制度，从公费医疗、劳保医疗到城镇职工基本医疗、新型农村合作医

疗，再到城镇居民基本医疗，就此医保制度的背景进行了全面系统的概述。

然后，本文利用风险损失理论中的个体风险和聚合风险模型，分析出现行损

失的均值及方差，然后基于损失的分布，利用纯保费法和 GLM 模型厘定出初步的

保费值。由于历年的损失值都是随机波动的，并不一定具有完全的可信性，所以

本文进一步根据 Bühlmann 信度理论模型由损失值算出保费的信度因子为 0.399，

则现行保费的可信度为 0.601。信度理论模型下的置信保费为 186 元，同比福州

市现行平均参保人群的筹资标准提高了 3.3%，即从模型理论来看，需要提高 3.3%

的保费方可使基金平衡运行。

对于现行医保中存在的诸多问题，本文认为其根源在于缺乏有效的激励。通

过建立的 NCD 系统分析，解得 NCD 系统下的置信保费为 244



，进而确定出政府

和个人的筹资标准。当基金筹资水平因子

%74

1



时，即系统的实施使基金的报

销额度减少 26%及以上时，就可达到一种双赢的效果，一方面使居民补助比例由

原来的 50%提高到平均的 65.6%，另一方面筹资水平减少，使政府的负担减轻了；

当

%74

1



时，效果不明显，虽然一方面补助水平增加，但另一方面筹资水平也

增加了。

对于基金的平衡测算，只要保证基金筹资水平因子



与基金损失因子



的

比值，即效果因子



大于等于 0.748 时，基金就可正常稳定运行。即在 NCD 系

统的激励下，基金筹资水平因子



为原来的 90%时，只要保证基金损失额度控制

在原来的 120%或 120%以内，基金就可以达到平衡或有所结余；同理基金筹资水

平因子



为原来的 80%时，只要保证损失额度控制在原来的 107%或 107%以内，

基金就可以达到平衡或有所结余。

最后，本文基于以上研究成果，对福州市城镇居民基本医疗保险现存的问题

提出了针对性的建议，如完善城镇居民医疗保险制度的设计、建立城镇居民医疗

保险制度的量化指标体系、建立城镇居民医疗保险的 NCD 激励系统等，对福州市

乃至全国城镇居民基本医疗保险的进一步实施具有重要的参考价值。

关键词: 城镇居民基本医疗保险风险模型理论信度模型理论

NCD 激励系统基金筹资水平因子基金损失因子

ABSTRACT

The basic medical insurance for urban residents ,to protect the non-employee

residents who were not covered by the urban employees’ basic medical insurance and

the new type rural cooperative medical insurance, started in July 2007 .It is an

important part of our country's health care system and a necessary step toward

universal health insurance. Since the launch of this policy, it has achieved quite good

results, but its further development and implement was impeded, because of its

deficiency of quantitative indicators and incentive measures. There are still difficult

medical treatment, expensive medical costs and the excessive growth of medical

expense. This problem has been a leading research topic of the academia.

This paper analyzed the above problem, taking Fuzhou City for example, which

is the first batch of the policy, in the hope of provide feasible suggestions for the

further implement of the basic medical insurance for urban residents of our country.

Firstly, this paper comprehensively outlined the background on the Medicare system,

from the publicly-funded health care, the labor to urban basic medical health care, to

the new type rural cooperative medical care, and the basic medical care for urban

residents, discussing the medical security system that gradually covered all civilian

step by step.

Using the theory of individual risk and aggregate risk model, this paper analyzed

the mean and variance of loss, and then redefined the initial premium using the pure

premium method and GLM models, base on the distribution of the loss. As the loss

values of calendar year randomly fluctuate, it do not have full credibility. This paper

worked out the reliability factor of the premium was 0.399 with the Bühlmann

reliability theory model by loss values. So, the credibility of the current premium was

0.601, and the confidence premium was 186 Yuan, it increased by 3.3% compared

with the existing average funding criteria of the insured population of Fuzhou city.

From the theory of the model, it needed a 3.3% increasing of the premium that may

enable the fund to be balanced.

For many present problems that exist in health insurance, this paper argues that it

is rooted in a lack of incentive system. Through the establishment of the NCD system

analysis, this paper worked out the confident premium under the NCD system was

244



, and then identified funding criteria of the government and individuals. When

the financing level factor of funds

%74

1



, namely the implementation of the

system enabled the funds reduce the reimbursement amount for 26% or above, it

could achieve a win-win effect, on the one hand the proportion of subsidy of the

residents increased from 50% to an average of 65.6% , on the other hand, the funding

levels and the burden of the Government reduced; when

%74

1



, the effect was not

obvious, on the one hand the levels of subsidy increased, on the other hand the level

of funding has also increased.

For the balance calculation of the funds, as long as the ratio of financing level

factor of funds



and loss factor of funds



, namely the effective factor, was

bigger than or equaled with 0.748, the funds could normally and stably operate. Under

the incentive of the NCD system, when financing level factor of the funds



is 90%

of the original value, as long as the amount of loss of the fund was controlled at 120%

or less than 120% of the original value, the funds can achieve balance or surplus ;

when financing level factor of the funds



is 80% of the original value , as long as

the amount of loss of the fund was controlled at 107% or less than 107% of the

original value, the funds can achieve balance or surplus.

Finally, this paper put forward some corresponding suggestions about the

existing problems of the basic medical insurance for urban residents in Fuzhou city,

based on the above research results, such as to improve the design of the basic

medical insurance for urban residents, and to establish a quantitative index system and

a NCD incentive systems for the basic medical insurance for urban residents. It has

important reference value for promoting the basic medical insurance for urban

residents in Fuzhou as well as for the further implementation of the whole country.

Key word ：The basic medical insurance for urban residents,

Risk model theory, Reliability model theory, NCD incentive system,

Financing level factor of funds, Loss factor of funds

中文摘要

ABSTRACT

第一章绪论 ...................................................... 1

§1.1 引言 ...................................................... 1

§1.2 研究目的及意义 ............................................ 2

§1.3 论文架构和创新点 .......................................... 3

§1.3.1 研究框架和思路 .......................................3

§1.3.2 选择的研究方法和创新点 ...............................4

第二章城镇居民医疗保险的一般性理论研究 ............................ 5

§2.1 研究背景 .................................................. 5

§2.1.1 公费医疗和劳保医疗制度 ...............................5

§2.1.2 城镇职工医疗保险制度 .................................6

§2.1.3 新型农村合作医疗保险 .................................7

§2.1.4 城镇多层次医疗保障体系 ...............................9

§2.1.5 城镇居民医疗保险制度 ................................10

§2.1.6 全民医保 ............................................11

§2.2 城镇居民医疗保险概述 ..................................... 11

§2.3 城镇居民医疗保险建立的必要性分析 ......................... 12

§2.4 国内外研究现状 ........................................... 13

§2.4.1 国内研究现状 ........................................13

§2.4.2 国外研究现状 ........................................14

第三章医疗保险的统计方法 ......................................... 17

§3.1 社会医疗保险精算的基本思想 ............................... 17

§3.2 医疗保险的损失模型研究 ................................... 18

§3.2.1 短期个体风险模型 ....................................18

§3.2.2 短期聚合风险模型 ....................................22

§3.3 费率的厘定方法 ........................................... 27

§3.3.1 费率厘定的基本因素 ..................................27

§3.3.2 传统估计方法 ........................................28

§3.3.3 广义线性模型 ....................................... 31

§3.4 保费的置信模型 ........................................... 32

§3.4.1 完全信度与部分信度模型 ..............................33

§3.4.2 Bühlmann 信度模型 ...................................35

§3.5 无赔款优待系统 ........................................... 36

§3.5.1 系统简介 ............................................36

§3.5.2 系统转移概率 ........................................37

§3.5.3 系统的稳定速度 ......................................38

第四章基于统计模型的城镇居民医疗保险的基金平衡测算 ............... 41

§4.1 城镇居民医疗保险基金简介 ................................. 41

§4.1.1 医疗保险基金筹资原则与筹资水平 ......................41

§4.1.2 医疗保险基金的支付水平 ..............................44

§4.2 城镇居民医疗保险基金的收支平衡管理 ....................... 45

§4.2.1 现收现付制 ..........................................45

§4.2.2 基金的运行模式 ......................................46

§4.2.3 基金的收支平衡 ......................................48

§4.3 城镇居民医疗保险保费的估计 ............................... 49

§4.3.1 城镇居民医疗保险保费定价原理 ........................49

§4.3.2 置信模型下的筹资标准 ................................49

§4.3.3 无赔款优待系统下的保费估计 ..........................50

§4.3.4 城镇居民医疗保险基金的平衡测算 ......................50

第五章福州市城镇居民医疗保险的实证研究 ........................... 53

§5.1 福州市城镇居民医疗保险改革现状 ........................... 53

§5.1.1 福州市医改历程 ......................................53

§5.1.2 福州市医改成效 ......................................53

§5.2 福州市城镇居民医疗保险的实证研究 ......................... 56

§5.2.1 城镇居民医疗保险数据来源 ............................56

§5.2.2 描述统计分析 ........................................56

§5.2.3 模型的建立 ..........................................63

§5.2.4 福州市城镇居民医疗保险保费估测 ......................65

§5.2.5 福州市城镇居民医疗保险基金的运行分析 ................67

§5.3 福州市城镇居民医疗保险存在的问题 ......................... 68

§5.4 完善城镇居民医疗保险制度的措施 ........................... 69

§5.4.1 完善城镇居民医疗保险制度的设计 ......................69

§5.4.2 建立城镇居民医疗保险制度的量化指标体系 ..............70

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摘要：

摘要城镇居民基本医疗保险于2007年7月开始试点实施，主要保障未被城镇职工基本医疗保险和新型农村合作医疗保险覆盖的城镇非从业居民，是我国医疗保障体系的重要组成部分，是我国走向全民医保的必然步骤。自启动试点以来，城镇居民基本医疗保险虽然成效颇丰，但是由于缺乏量化指标体系和激励措施，使其进一步的发展、实施受到阻碍，看病难、看病贵、医疗费用增长过快的现象仍然存在。这一难点已成为学术界研究的前沿问题。本文就上述问题，以首批试点的福州市为例展开剖析，以期对我国城镇居民基本医疗保险的进一步实施提供可行的建议。本文首选分步论述了逐渐覆盖全民的医疗保险制度，从公费医疗、劳保医疗到城镇职工基本医疗、新型农村合作...

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