社会医疗保险学

社会医疗保险学 社会医疗保险学重点 第一章(绪论)(,,,) 一、 社会医疗保险:通过立法，强制性地由国家、单位和个人缴纳医疗保险费，建立医疗保险基金，当个人因 疾病需要获得必需的医疗服务时，由社会医疗保险机构按规定提供医疗费用补偿的一种社会保险。它同社会 生育保险、社会养老保险、社会工伤保险、社会失业保险共同构成社会保险。而社会保险又与社会救济、社会福 利、社会优抚共同构成社会保障体系。 二、社会医疗保险的性质 1、福利性 2、强制性 3、经济性 4、公益性 三、社会医疗保险的特征 1、社会医疗保险对象的普遍性; 2、社会医疗保险涉及面的广泛性和复杂性; 3、社会医疗保险赔付的短期性与经常性; 4、社会医疗保险补偿形式的特殊性; 5、社会医疗保险费测算的复杂性。 四、社会医疗保险的基本原则 1、社会化原 2、全员参保原则 3、保障基本医疗需求原则 4、公平与效率相结合原则 5、财政专户管理、专款专用原则 6、费用三方分担原则 7、以收定支，收支平衡，略有结余原则 8、合理偿付医疗费用原则 9、谁参保，谁受益原则 10、属地化管理原则 五、社会医疗保险的作用 (一)社会医疗保险的基本功能 1、稳定社会生活 2、再分配功能 3、扩大有效需求 4、保障社会生产 (二)社会医疗保险的特殊功能 1、保障居民健康 2、规范卫生服务供方和需方的行为 containing gross errors, should immediately test if determined when monitoring data contain a large systematic errors, you should analyze ... 10.9.1 10.9 quality inspection and acceptance monitoring of equipment inspection and delivery inspection all our procurement monitoring equipment shall be as provided in section 10.2 of the terms of this technology, inspection and acceptance of delivery, and should include monitoring equipment factory inspection and test reports and delivery acceptance, acceptance certificate information supervising people. 10.9.2 monitoring instruments installed inbuilt quality check each measuring point measuring instruments and equipment after completion of installation, Embedment, immediately to inspect and test the quality of equipment installation, Embedment, and confirmed by the supervisor to check the quality before being allowed to begin monitoring contract work. Section 10.10 of completion on completion of each observation all monitoring equipment installed after laying, of 52nd of the references to this agreement the terms of the contract provisions, apply to the supervisor to monitor the project's acceptance of special, and according to the technical provisions 16.1. the 3、促进医疗卫生服务社会化 1、社会医疗保险的筹资来源不包括:() A、国家 B、企业 C、个人 D、社会 2、( )是保险的基本职能。 A(经济补偿 B. 分散风险 C(融通资金 D. 防灾防损 第二章 医疗保险模式(,,,,,) 一、医疗保险模式可分: ?国家医疗保险模式(亦称政府医疗保险) 概念:医疗保险基金由国家财政支出，纳入国家预算，通过中央或地方政府实行国民收入再分配，有地拨给有关部门或直接拨给医疗服务提供方，医疗保险享受对象看病时，基本上不需要支付费用。 代表国家:英国 优点: 1) 以政府税收筹资，资金来源稳定，社会共济能力强; 2)卫生机构公有制为主，政府可直接参与管理或调控; 3)公共卫生和预防服务由政府负责，住院费用由政府拨付。医院医生为国家公职人员，领取工资; 4)医疗保险基本覆盖全民，免费低费服务，公平性高; 5)卫生资源配置、医疗服务价格等主要通过政府计划来进行调节，政府对医疗费用的控制能力较强。 主要局限: 1)由于公有制和计划调节造成效率低下，计划难以准确、及时反映居民需求的变化; 2)医院、医生服务积极性不高，供需之间矛盾较突出; 3)筹资渠道单一，财政负担较重。 ?社会医疗保险模式 概念:通过国家立法形式强制实施的一种医疗保险制度，其医疗保险基金主要是由雇主和雇员缴纳，政府酌情补贴，参保者及其家属因患病、受伤或生育而需要医治时，由社会医疗保险机构提供医疗服务和物资帮助。此模式在管理体制上属于计划与市场相结合的体制。 代表性国家:德国。 主要优点: 1)政府不参与法定医疗保险的具体操作，国家也没有统一的医疗保险经办机构，可减轻各级政府行政负担; 2)政府担当中介及仲裁角色，能较好地处理各方利益冲突; containing gross errors, should immediately test if determined when monitoring data contain a large systematic errors, you should analyze ... 10.9.1 10.9 quality inspection and acceptance monitoring of equipment inspection and delivery inspection all our procurement monitoring equipment shall be as provided in section 10.2 of the terms of this technology, inspection and acceptance of delivery, and should include monitoring equipment factory inspection and test reports and delivery acceptance, acceptance certificate information supervising people. 10.9.2 monitoring instruments installed inbuilt quality check each measuring point measuring instruments and equipment after completion of installation, Embedment, immediately to inspect and test the quality of equipment installation, Embedment, and confirmed by the supervisor to check the quality before being allowed to begin monitoring contract work. Section 10.10 of completion on completion of each observation all monitoring equipment installed after laying, of 52nd of the references to this agreement the terms of the contract provisions, apply to the supervisor to monitor the project's acceptance of special, and according to the technical provisions 16.1. the 3)社会医疗保险制度统一、运行集中; 4)保险效率高、管理成本低。 社会医疗保险模式突出问题: 1)对预防服务重视不够; 2)医疗费用增长过快。 ?市场型医疗保险模式 概念:又称商业型医疗保险模式，是把医疗保险当作一种特殊商品，主要通过市场机制来筹集费用和提供服务。此模式下，医疗保险的资金主要来源于参保者个人及其雇主所交纳的保险费，医疗服务的供给、医疗服务的价格等是通过市场竞争和和市场调节来决定的，政府干预较少。 代表国家:美国。 商业医疗保险制度的优点: 1)管理多部门、多层次，各级政府和民间机构分别管理，相互协作，形成遍布全美国医疗保险组织机构体系; 2)国家预算支出保两头、舍中间，即重点保障老人和儿童，劳动人口由雇主与个人负担; 3)体现效率原则，多贡献多受益，不搞平均; 4)医疗保险制度多元化。 商业医疗保险制度的主要问题: 费用负担过重，欺骗与作弊行为难禁(答题方向:商业保险以营利为目的，对投保人进行风险选择); 1) 2)医疗保险难以保证社会公平。 ?储蓄医疗保险模式 概念:是强制储蓄保险的一种形式。它是一种通过立法强制劳方或劳资双方缴费，以雇员的名义建立保健储蓄帐户，用于支付个人及家庭成员的医疗费用的医疗保险制度。代表国家:新加坡。 储蓄医疗保险模式主要特点: 资金纵向积累，筹资机制呈“T”型结构，个人纵向积累与横向的社会共济统筹相结合，利于抑制对医疗服务的过度利用和超前消费。 储蓄医疗保险模式主要问题: 过分强调效率，忽视了公平性，对于收入低或无收入的人群，因其个人帐户资金储蓄不足，患病时就可能没钱治病。 二、以上几种主要国家医疗保险模式的比较 containing gross errors, should immediately test if determined when monitoring data contain a large systematic errors, you should analyze ... 10.9.1 10.9 quality inspection and acceptance monitoring of equipment inspection and delivery inspection all our procurement monitoring equipment shall be as provided in section 10.2 of the terms of this technology, inspection and acceptance of delivery, and should include monitoring equipment factory inspection and test reports and delivery acceptance, acceptance certificate information supervising people. 10.9.2 monitoring instruments installed inbuilt quality check each measuring point measuring instruments and equipment after completion of installation, Embedment, immediately to inspect and test the quality of equipment installation, Embedment, and confirmed by the supervisor to check the quality before being allowed to begin monitoring contract work. Section 10.10 of completion on completion of each observation all monitoring equipment installed after laying, of 52nd of the references to this agreement the terms of the contract provisions, apply to the supervisor to monitor the project's acceptance of special, and according to the technical provisions 16.1. the 1、通过强制性社会保险原则，由国家、单位和个人共同缴纳保险费，把具有不同医疗需求群体的资金集中起来，进行再分配，当个人因疾病接受医疗服务时，由社会医疗保险机构提供医疗保险费用补偿的一种社会保险制度称之为( ) A、社会医疗保险 B、商业医疗保险 C、补偿医疗保险 D、个人自我保险 2(新加坡的医疗保险模式是() A(储蓄医疗保险 B(社会医疗保险 C(国家医疗保险 D(商业医疗保险 3(以下哪一个国家是实施商业医疗保险的典型代表() A(日本 B(德国 C(英国 D(美国 第三章 社会医疗保险系统(,,,) 一、医疗保险系统:在医疗需求与供给以及医疗费用的筹集管理和支配过程中，各种要素相互作用、相互依存而形成的一个有机整体，它维持着医疗保险活动的进行和开展。 containing gross errors, should immediately test if determined when monitoring data contain a large systematic errors, you should analyze ... 10.9.1 10.9 quality inspection and acceptance monitoring of equipment inspection and delivery inspection all our procurement monitoring equipment shall be as provided in section 10.2 of the terms of this technology, inspection and acceptance of delivery, and should include monitoring equipment factory inspection and test reports and delivery acceptance, acceptance certificate information supervising people. 10.9.2 monitoring instruments installed inbuilt quality check each measuring point measuring instruments and equipment after completion of installation, Embedment, immediately to inspect and test the quality of equipment installation, Embedment, and confirmed by the supervisor to check the quality before being allowed to begin monitoring contract work. Section 10.10 of completion on completion of each observation all monitoring equipment installed after laying, of 52nd of the references to this agreement the terms of the contract provisions, apply to the supervisor to monitor the project's acceptance of special, and according to the technical provisions 16.1. the 二、社会医疗保险四方三角关系: 被保险人 税收 补贴 提供服务 选择服务 缴纳保费 报销 政府 分配 补偿 确定服务项目 医疗保险机构 医疗服务提供者 支付费用、监督 三、医疗保险需求 (一)医疗保险需求的概念和条件 1、医疗保险需求:在一定时期内，一定价格水平上消费者愿意并且能够购买的医疗保险服务量，即医疗保险 机构所提供的一定价格条件下的经济保障需要量，用货币计量单位表示即为医疗保险金额。 2、医疗保险需求形成的条件 (1)医疗保险消费意愿。 (2)货币支付能力。 (3)需求者投保的标的物符合医疗保险机构的经济技术。 (二)医疗保险需求的影响因素 1、疾病发生的概率及损失程度 2、医疗保险的价格 3、消费者的收入 4、承保的范围 5、医疗费用的负担方式:扣除保险、共付保险、限额保险、混合保险四种。 6、医疗服务的供给 7、医疗保健制度 containing gross errors, should immediately test if determined when monitoring data contain a large systematic errors, you should analyze ... 10.9.1 10.9 quality inspection and acceptance monitoring of equipment inspection and delivery inspection all our procurement monitoring equipment shall be as provided in section 10.2 of the terms of this technology, inspection and acceptance of delivery, and should include monitoring equipment factory inspection and test reports and delivery acceptance, acceptance certificate information supervising people. 10.9.2 monitoring instruments installed inbuilt quality check each measuring point measuring instruments and equipment after completion of installation, Embedment, immediately to inspect and test the quality of equipment installation, Embedment, and confirmed by the supervisor to check the quality before being allowed to begin monitoring contract work. Section 10.10 of completion on completion of each observation all monitoring equipment installed after laying, of 52nd of the references to this agreement the terms of the contract provisions, apply to the supervisor to monitor the project's acceptance of special, and according to the technical provisions 16.1. the 8、保险意识 9、其它因素(健康、年龄、职业、文化等) 四、医疗保险供给 (一)医疗保险供给的概念和形式 1、医疗保险供给:在一定时期内，一定价格水平上医疗机构愿意且有能力提供的医疗保险产品的数量。其内容用医疗保险的“承保能力”表示，包括能提供的总医疗保险金额数量、能提供的特定险种各自的可保险金额数量、对人们疾患或可保风险的保险总金额。 2、医疗保险供给的表现形式 (1)可见形式:直接医疗服务。 (2)不可见形式:医疗保险机构对所有参保人提供的心理安全保障。 (二)医疗保险供给的影响因素 1、医疗保险价格 2、承保能力 3、医疗保险成本 4、缴费能力 5、医疗服务因素 、政府行为因素 6 五、医疗保险供给与需求的平衡 (一)医疗保险供需平衡的概念 医疗保险供需平衡:一定价格水平上，医疗保险供给量与医疗保险需求量相等或基本相等。 影响此平衡的因素多种，包括所有影响需求与供给的各种因素。 (二)实现医疗保险供求均衡的措施 (1)医疗保险供求调查 (2)医疗保险供求预测 (3)医疗保险决策 六、医疗保险市场存在的问题 1、逆向选择:不参保、选择性参保、投机性参保; 2、“道德损害”下的医疗保险需求; 3、风险选择:保险公司为获取更大利润而选择高收入、低风险健康人群参保; 4、三角交换关系:第三方保险机构付费，削弱了消费者和供给者的经济限制，导致资源的使用缺乏节制。 containing gross errors, should immediately test if determined when monitoring data contain a large systematic errors, you should analyze ... 10.9.1 10.9 quality inspection and acceptance monitoring of equipment inspection and delivery inspection all our procurement monitoring equipment shall be as provided in section 10.2 of the terms of this technology, inspection and acceptance of delivery, and should include monitoring equipment factory inspection and test reports and delivery acceptance, acceptance certificate information supervising people. 10.9.2 monitoring instruments installed inbuilt quality check each measuring point measuring instruments and equipment after completion of installation, Embedment, immediately to inspect and test the quality of equipment installation, Embedment, and confirmed by the supervisor to check the quality before being allowed to begin monitoring contract work. Section 10.10 of completion on completion of each observation all monitoring equipment installed after laying, of 52nd of the references to this agreement the terms of the contract provisions, apply to the supervisor to monitor the project's acceptance of special, and according to the technical provisions 16.1. the ,、以下哪个主体在医疗保险系统中处于管理者地位( ) A、医疗保险机构 B、医疗服务的提供者 C、医疗保险的参保人 D、政府 ,、人们事前的机会主义倾向往往导致( ) A、道德风险 B、败德行为 C、逆向选择 D、以上都不是 第四章为非重点内容，此处不再赘述。 第五章 社会医疗保险基金的筹集(A/C) 一、基金筹集原则 1、法制化原则; 2、多方负担原则; 3、“以收定支、收支平衡、略有结余”的原则; 4、基本保障的原则; 5、统一费率的原则; 6、相对稳定原则; 7、现收现付制原则。 二、医疗保险基金的筹集渠道 1、雇主出资 2、个人出资 3、国家补贴 4、基金利息收入 5、调剂收入 6、转移收入 7、其他收入 三、保险基金的筹集模式 containing gross errors, should immediately test if determined when monitoring data contain a large systematic errors, you should analyze ... 10.9.1 10.9 quality inspection and acceptance monitoring of equipment inspection and delivery inspection all our procurement monitoring equipment shall be as provided in section 10.2 of the terms of this technology, inspection and acceptance of delivery, and should include monitoring equipment factory inspection and test reports and delivery acceptance, acceptance certificate information supervising people. 10.9.2 monitoring instruments installed inbuilt quality check each measuring point measuring instruments and equipment after completion of installation, Embedment, immediately to inspect and test the quality of equipment installation, Embedment, and confirmed by the supervisor to check the quality before being allowed to begin monitoring contract work. Section 10.10 of completion on completion of each observation all monitoring equipment installed after laying, of 52nd of the references to this agreement the terms of the contract provisions, apply to the supervisor to monitor the project's acceptance of special, and according to the technical provisions 16.1. the 1、现收现付制(一种由用人单位和职工个人按一定缴费率当年缴纳的医疗保险金，刚好能够满足或略大于当年的医疗费用支出) 2、部分积累制(一种介于现收现付与完全积累模式之间混合筹资方式)。 3、完全积累制(一种以远期纵向收支平衡原则为指导的基金筹集方式)。 目前的国情来看，我国现阶段主要采用现收现付制， 这种筹资模式的特点是: (1)“以支定收”，每年筹集的医疗保险费与当年的医疗保险基金支出基本平衡，并略有结余; (2)费率调整灵活，易于操作; (3)医疗费用代际转移，体现了人与人之间的横向调剂 (4)调整和缩小了社会成员之间的收入差距，消除了国民收入初次分配的悬殊，实现了国民收入二次分配的公平性。 (1)下列选项中，采用近期横向收付平衡筹资原则的是( ) A.现收现付模式 B.完全积累模式 C.部分积累模式 D.预收预付模式 (2)下列选项中，可以作为社会保险基金来源的是( ) A.行政罚款 B.银行贷款 C.企业投资 D.社会捐赠 ,,, 第六章 社会医疗保险费用的支付(C/C) 一、医疗保险费用支付的途径和方法 1)需方的支付途径和方式: ?起付线:是指被保险人在就医时先自付一笔规定的费用，其余费用全部或部分由保险机构支付。由被保险人自付的医疗费用水平，被称为起付线或起保线。 优点:?管理成本较少;?增强被保险人费用意识;?有利于保大病。 关键即难点:起付线的确定 containing gross errors, should immediately test if determined when monitoring data contain a large systematic errors, you should analyze ... 10.9.1 10.9 quality inspection and acceptance monitoring of equipment inspection and delivery inspection all our procurement monitoring equipment shall be as provided in section 10.2 of the terms of this technology, inspection and acceptance of delivery, and should include monitoring equipment factory inspection and test reports and delivery acceptance, acceptance certificate information supervising people. 10.9.2 monitoring instruments installed inbuilt quality check each measuring point measuring instruments and equipment after completion of installation, Embedment, immediately to inspect and test the quality of equipment installation, Embedment, and confirmed by the supervisor to check the quality before being allowed to begin monitoring contract work. Section 10.10 of completion on completion of each observation all monitoring equipment installed after laying, of 52nd of the references to this agreement the terms of the contract provisions, apply to the supervisor to monitor the project's acceptance of special, and according to the technical provisions 16.1. the 过低:费用约束力量弱 过高:抑制需求，小病变大病 道德损害)的问题。 存在的问题:超过起付线后，过量服务利用( ?共付保险(co-insurance)，又称按比例自付，是指保险机构和被保险人按一定比例共同支付医疗费用，这一定比例又称共付率，如共付率80,，即个人支付80,，保险机构支付20,。 优点:操作简单、易于管理;控制费用;降低供方医疗服务价格。 关键即难点:共付率的确定; 过高:抑制需求 过低:不利于费用控制 存在的问题:对不同人群制定相同的共付率，不符合垂直公平原则。 解决:分级共付。不同人群制定不同共付率 ?限额保险-封顶线 保险机构为被保险人医疗费用补偿设立一个最高限额(封顶线)，保险机构只支付限额内的医疗费用，超出限额的医疗费用由被保险人自己负担。 与扣除保险相反的费用分担方式 优点:社会经济发展水平较低时，保证基本医疗服务;供、需双方行为都可受到控制;防止小病不治酿成大病。 存在问题:从保险本质来看，大病、重病的发生概率小，但经济风险高，是所有医疗服务中最符合保险原理、最需要保险的部分，在保险方式单一的情况下，难以对大病、重病医疗提供有效保障。 ?混合保险 混合保险就是将上述扣除保险、共付保险和限额保险的内容结合起来应用的费用分析方式。 2)供方的费用支付方式 (一)按服务项目支付 (二)按人头付费制(三)总额预算制 (四)按病种付费制(DRGS) (五)按定额付费 containing gross errors, should immediately test if determined when monitoring data contain a large systematic errors, you should analyze ... 10.9.1 10.9 quality inspection and acceptance monitoring of equipment inspection and delivery inspection all our procurement monitoring equipment shall be as provided in section 10.2 of the terms of this technology, inspection and acceptance of delivery, and should include monitoring equipment factory inspection and test reports and delivery acceptance, acceptance certificate information supervising people. 10.9.2 monitoring instruments installed inbuilt quality check each measuring point measuring instruments and equipment after completion of installation, Embedment, immediately to inspect and test the quality of equipment installation, Embedment, and confirmed by the supervisor to check the quality before being allowed to begin monitoring contract work. Section 10.10 of completion on completion of each observation all monitoring equipment installed after laying, of 52nd of the references to this agreement the terms of the contract provisions, apply to the supervisor to monitor the project's acceptance of special, and according to the technical provisions 16.1. the ,,, 案例 ? 一位北京退休职工，60岁，个人帐户1200元，患高血压、冠心病，一年内共发生如下几笔医疗费用: 1、门诊:一年支出2200元 起付线1300元以下，个人账户支付; 自付30%，则报销630元，个人自负 起付线1300元以上的900元，到大额互助报销: 不满70周岁按70%支付, 270元,北京市补充医疗再报销50%，即135元，共765元。 单位补充医疗保险报销:1000至1300元部分报销90%=270元，自负一半135元再报销50%为67.50元，共337.50元。 社保门诊和单位补充保险两项合计报销1102.5元。个人负担1097.5元。加上个人账户的1200元，基本保证职工就医需要。 计算步骤: 第一步:社保基本医疗部分 (2200-1300)×70%=630 北京市统一补充医疗保险部分 2200-1300=900-630=270 ×50%=135 合计765元。(医保存折) 第二步:本单位补充医疗保险部分 (1300-1000)×90%=270元 135 ×50%=67.50元 containing gross errors, should immediately test if determined when monitoring data contain a large systematic errors, you should analyze ... 10.9.1 10.9 quality inspection and acceptance monitoring of equipment inspection and delivery inspection all our procurement monitoring equipment shall be as provided in section 10.2 of the terms of this technology, inspection and acceptance of delivery, and should include monitoring equipment factory inspection and test reports and delivery acceptance, acceptance certificate information supervising people. 10.9.2 monitoring instruments installed inbuilt quality check each measuring point measuring instruments and equipment after completion of installation, Embedment, immediately to inspect and test the quality of equipment installation, Embedment, and confirmed by the supervisor to check the quality before being allowed to begin monitoring contract work. Section 10.10 of completion on completion of each observation all monitoring equipment installed after laying, of 52nd of the references to this agreement the terms of the contract provisions, apply to the supervisor to monitor the project's acceptance of special, and according to the technical provisions 16.1. the 合计337.50元。(工资卡) 两项合计报销1102.50元。 。 ?住院:在三级医院，住院处收押金(个人自付9%)，住院支出医疗费2万元 医院结算:分段支付执行起付线1300元到3万元，1300元以下自付， 个人自付一:18700×9,,1683元; 个人自付一部分再由北京市补充医疗保险报一半，即个人自付1683×50%=841.5元 个人自付总计:841.5+1300=2141.5元, 单位补充医疗保险报销自负的部分为:2141.50×90%=1927.35元。实际个人负担为:214.15元 二、供方的费用支付 医疗保险费用偿付 医疗保险费用偿付是指医疗保险机构作为付款人，在被保险人获得医疗服务后，向医疗服务的提供方(即医院)支 付医疗费用的行为。 )医疗保险费用的支付方式中，相当于为供方设立了一个封顶线的是( ) (1 A.按项目付费方式 B.按服务单元付费方式 C.按人头付费方式 D.总额预算付费方式 (2)我国现行城镇职工基本医疗保险制度规定，起付标准以下的医疗费用由( ) A.统筹基金支付 B.财政补贴支付 C.个人账户或个人支付 D.企业补贴支付 第七章 社会医疗保险基金的管理(B) 一、社会医疗保险基金的管理原则: 1、集中管理，控制风险 2、部门协调，各行其责 3、专款专用，实现收支两条线 4、量入为出，收支平衡 5、效率原则 二、社会医疗保险基金管理的主要内容 containing gross errors, should immediately test if determined when monitoring data contain a large systematic errors, you should analyze ... 10.9.1 10.9 quality inspection and acceptance monitoring of equipment inspection and delivery inspection all our procurement monitoring equipment shall be as provided in section 10.2 of the terms of this technology, inspection and acceptance of delivery, and should include monitoring equipment factory inspection and test reports and delivery acceptance, acceptance certificate information supervising people. 10.9.2 monitoring instruments installed inbuilt quality check each measuring point measuring instruments and equipment after completion of installation, Embedment, immediately to inspect and test the quality of equipment installation, Embedment, and confirmed by the supervisor to check the quality before being allowed to begin monitoring contract work. Section 10.10 of completion on completion of each observation all monitoring equipment installed after laying, of 52nd of the references to this agreement the terms of the contract provisions, apply to the supervisor to monitor the project's acceptance of special, and according to the technical provisions 16.1. the 1、基金征缴和稽核 2、医疗费用的审核和支付 财务管理 3、 4、风险管理 5、监督管理 (1)从法律和规则的角度来看，社会保险基金监管是指( ) A.基金检查 B.基金管理 C.基金审计 D.基金核算 第八章 社会医疗管理的医疗服务管理(A) 一、“两个定点”管理:是指对定点医疗机构和定点零售药店的管理。 二、“三个目录”管理:是指对基本医疗保险用药范围、基本医疗保险诊疗项目、基本医疗保险服务设施进行管 理。 三、什么是基本医疗保险药品目录, 答:基本医疗保险目录是指保证职工临床治疗必需的，纳入基本医疗保险 给付范围的药品目录。它是由甲类目录和乙类目录组成。 “甲类目录”的药品是指全国基本统一的，能保证临床治疗基本需要的药 物。这类药物被纳入基本医疗基金给付范围，并按基本医疗保险的给付标准支付费用。 “乙类目录”的药物是指基本医疗保险基金部分支付费用的药物。这类药 物先由患者自付一定比例的费用后，按基本医疗保险有关规定支付费用。 (1)基本医疗保险“三个目录”中没有以下哪一项( )。 A.医用材料目录 B.诊疗项目 C.药品目录 D.医疗服务设施标准 第九章 社会医疗保险管理信息系统 containing gross errors, should immediately test if determined when monitoring data contain a large systematic errors, you should analyze ... 10.9.1 10.9 quality inspection and acceptance monitoring of equipment inspection and delivery inspection all our procurement monitoring equipment shall be as provided in section 10.2 of the terms of this technology, inspection and acceptance of delivery, and should include monitoring equipment factory inspection and test reports and delivery acceptance, acceptance certificate information supervising people. 10.9.2 monitoring instruments installed inbuilt quality check each measuring point measuring instruments and equipment after completion of installation, Embedment, immediately to inspect and test the quality of equipment installation, Embedment, and confirmed by the supervisor to check the quality before being allowed to begin monitoring contract work. Section 10.10 of completion on completion of each observation all monitoring equipment installed after laying, of 52nd of the references to this agreement the terms of the contract provisions, apply to the supervisor to monitor the project's acceptance of special, and according to the technical provisions 16.1. the 一、社会医疗保险信息 ?含义:(health insurance management information)是反映社会医疗保险活动过程的发生、发展、结果及其影响因素的定性和定量化数据、情报等。 ?特征:综合性、流动性、随机性 二、社会医疗保险管理信息系统(HIMS) ?概念:是一个以提高医疗保险信息管理效率及科学决策为目的，由人、计算机技术及数据信息等要素组成，以医疗保险信息的收集、传递、贮存、加工维护为主体的有机整体。 ?医疗保险管理信息系统的特征: 1.系统的目的是提高医疗保险组织机构决策、执行、管理和控制的能力及水平; 2.系统由人、计算机技术、数据信息等要素构成; 3.数据及信息是系统加工(处理)对象; 4.系统的任务是收集、传递、贮存、加工和维护信息; 5.系统的结构由各要素间的关系决定。 ?医疗保险管理信息系统建设的原则: (一)整体的原则 (二)科学决策的原则 (三)以人为本的原则 第十章 社会医疗保险运行分析制度 一、社会医疗保险运行分析(shcial medical insurance operation analysis) ?概念:是运用统计学、经济学、保险学、医学等学科的方法。对社会医疗保险制度运行的投入、过程和结果进行科学分析研究，寻找社会医疗保险的发生发展规律，提高社会医疗保险制度效应的过程。 ?特点: 1)综合性强 2)数据量大 3)指标繁多 4)技术性强 二、社会医疗保险运行分析指标体系:参保、基金筹集、基金收支、受益面、医疗费用、医疗待遇、医疗服务。 第十一章 社会医疗保险风险管理 一、风险:指不确定性对既定目标造成的影响，习惯上被描述为潜在事件所致后果与其出现几率的组合，此影响可以是与预期目标的正向或负向偏差。。 二、风险评价:指对比风险分析结果和风险准则，决定风险及其程度是否被接受的过程。 三、风险评估:指由风险识别、风险分析和风险评价组成的整个过程。 containing gross errors, should immediately test if determined when monitoring data contain a large systematic errors, you should analyze ... 10.9.1 10.9 quality inspection and acceptance monitoring of equipment inspection and delivery inspection all our procurement monitoring equipment shall be as provided in section 10.2 of the terms of this technology, inspection and acceptance of delivery, and should include monitoring equipment factory inspection and test reports and delivery acceptance, acceptance certificate information supervising people. 10.9.2 monitoring instruments installed inbuilt quality check each measuring point measuring instruments and equipment after completion of installation, Embedment, immediately to inspect and test the quality of equipment installation, Embedment, and confirmed by the supervisor to check the quality before being allowed to begin monitoring contract work. Section 10.10 of completion on completion of each observation all monitoring equipment installed after laying, of 52nd of the references to this agreement the terms of the contract provisions, apply to the supervisor to monitor the project's acceptance of special, and according to the technical provisions 16.1. the 四、风险管理: 第十二章 社会医疗保险的评价 一、社会医疗保险评价(social medical insurance evaluation ) ?概念:是指根据国家社会保障发展的总目标，对其所分属的子项目——社会医疗保险展开并实施的全过程进行 综合分析与评价，总结经验、修正缺憾、完善社会医疗保险，以促进我国社会医疗保险制度的健康发展。 ?基本原则: 全面性 可操作性原则 客观性原则 动态性原则 ?目的:为完善政策提供依据 为保健人们健康需求达到最大的满足和提高 第十三章 社会医疗保险的法制管理 一、社会医疗保险法制管理的必要性 1、保证公民基本的人权保障 2、保证社会医疗保险基金有长期、稳定的来源 3、转变观念，合理利用卫生资源 4、保障广大劳动者基本医疗需求 5、协调好各方利益关系，保证医疗保险系统正常运转 二、社会医疗保险法律体系 1、全国人大 2、国务院 3、劳动社会保障 4、地方政府批准的法律法规 三、社会医疗保险法律涉及的法律 1、宪法 2、社会保障法 3、劳动法 4、合同法 5、保险法 第十四章 补充医疗保险 containing gross errors, should immediately test if determined when monitoring data contain a large systematic errors, you should analyze ... 10.9.1 10.9 quality inspection and acceptance monitoring of equipment inspection and delivery inspection all our procurement monitoring equipment shall be as provided in section 10.2 of the terms of this technology, inspection and acceptance of delivery, and should include monitoring equipment factory inspection and test reports and delivery acceptance, acceptance certificate information supervising people. 10.9.2 monitoring instruments installed inbuilt quality check each measuring point measuring instruments and equipment after completion of installation, Embedment, immediately to inspect and test the quality of equipment installation, Embedment, and confirmed by the supervisor to check the quality before being allowed to begin monitoring contract work. Section 10.10 of completion on completion of each observation all monitoring equipment installed after laying, of 52nd of the references to this agreement the terms of the contract provisions, apply to the supervisor to monitor the project's acceptance of special, and according to the technical provisions 16.1. the 一、补充医疗保险 1)概念:(广义)基本医疗保险以外的所有医疗保险形式。(狭义)对现有基本医疗保险制度下支付水平的补充， 是为了满足不同层次的医疗消费需求，补充超过基本医疗保险封顶线部分的医疗服务费用，以及基本医疗保险不 覆盖的服务项目费用。 2)特征: 1、补充性 2、非福利性 3、客观性 4、多样性 5、自愿性 3)意义: 1、有利于补充社会医疗保险体系的不足 2、有利于增进职工对企业凝聚力和向心力 3、有利于逐步过渡到全民医疗保险 4、有利于鼓励健康储蓄，引导合理消费 5、有利于强化医患制约关系 6、有利于增加卫生投入，促进卫生事业和保险事业的发展 4)作用: 1、减轻国家或政府的社会保障责任 2、减轻个人医疗负担 3、调节社会及个人收入分配 4、满足更大范围不同人群的需要 containing gross errors, should immediately test if determined when monitoring data contain a large systematic errors, you should analyze ... 10.9.1 10.9 quality inspection and acceptance monitoring of equipment inspection and delivery inspection all our procurement monitoring equipment shall be as provided in section 10.2 of the terms of this technology, inspection and acceptance of delivery, and should include monitoring equipment factory inspection and test reports and delivery acceptance, acceptance certificate information supervising people. 10.9.2 monitoring instruments installed inbuilt quality check each measuring point measuring instruments and equipment after completion of installation, Embedment, immediately to inspect and test the quality of equipment installation, Embedment, and confirmed by the supervisor to check the quality before being allowed to begin monitoring contract work. Section 10.10 of completion on completion of each observation all monitoring equipment installed after laying, of 52nd of the references to this agreement the terms of the contract provisions, apply to the supervisor to monitor the project's acceptance of special, and according to the technical provisions 16.1. the