Abstract

In the primary stage of socialism,social productivity is not yet well developed,material wealth is not rich enough,how to raise money in a fair and reasonable manner as much as possible to give national adequate protection,to solve the contradiction between health financing and treatment needs,both improve the core issue of social medical insurance system with Chinese characteristics,but also the implementation of the“13 th Five-Year Plan”proposed“to establish a stable and sustainable financing and treatment adjustment mechanism”.

This paper describes the mechanism of financing and treatment,mainly from the macro level analyze social financial balance mechanism of medical insurance system fund.From the associated mechanism of financing and treatment,the main financial mechanism of social medical insurance are“Income determines expenditure”and“Expenditure determines income”.“Income determines expenditure”is based on the funds that can be raised to determine the size of the expenditure,which is characterized by no deficit,in order to control costs. On the contrary,the basic principle of“Expenditure determines income”is to raise the required funds on the size of the expenditure requirements.

For the social medical insurance system,theoretically,the premium approval is based on the results of the risk assessment forecast,“Expenditure determines income”is the inherent law of the insurance system. However,in practice,China's urban workers basic medical insurance system has claimed that“Income determines expenditure”. What is the difference be tween this two principles?Why the basic medical insurance system of urban workers in China should be declared“Income determines expenditure”as its basic principle?How its practical effect?China's social medical insurance is possible and whether there is a need to turn to“Expenditure determines income”?On the face of it,these problems seem insignificant,but its essence,follow the different path to practice,will have different practical effects,some policy direction and even great disparity,directly related to two different concept,Concept and management service concept. It is directly related to the financial cost of the construction of social medical insurance system in our country. It is more concerned with the determination of social medical insurance system and the long-term sustainable development of the system. In reality,it is the core problem of social medical insurance system construction.

In order to clarify the basic connotation,origin and concrete method of the two kinds of financial balance mechanism with social medical insurance,analyzes the similarities and differences between the two basic concepts,clarify the basic concepts,to better guide the social medical insurance financial budget preparation work,this paper combs the basic concept,institutional characteristics and main functions of the social medical system in our country. From the comparative perspective of the combination of theory and practice,this paper analyzes the similarities and differences between the payment of funds and the balance.From the perspective of revenue and expenditure,to build a social medical insurance policy environment for China's financing and treatment associated with the mechanism model for the analysis and disclosure of China's social health insurance fund financial balance of the inherent nature of the law.

Through this study,it is found that social medical insurance financing and treatment is one of two aspects of things,both with the system of construction,mutual support,and mutual correlation. If the two are separated,follow the different path,may have a very different effect.The so-called so cial medical insurance financing and treatment of the associated mechanism,its essence is the system covers the population structure and its health status,medical consumption service prices and the level of treatment of the combined effect of the results of the elements involved in the interaction between the shifts.In the model of the mechanism of financing and treatment,the pay base is inversely proportional to the premium rate.Population burden coefficient,hospitalization rate,the average cost and wage rate,reimbursement ratio is proportional to premium rate.“Expenditure determines income”is the essence balance law of social health insurance,accept and policy of“Income determines expenditure”,there must be many problems.

Based on the correlation model constructed in this paper,the paper mainly carries out three levels of quantitative analysis：

First,build the mathematical model of the mechanism of financing and treatment,and verify and reveal the quantitative relationship between the endogenous factors of social medical insurance financing and treatment-related mechanism in the realistic environment.For example,under the established assumptions:the rate of hospitalization is increased by one percentage point,the premium rate is correspondingly increased by 0.29%;the average hospitalization fee is increased by one percentage point relative to the salary increase 1%,the premium rate is correspondingly increased by 0.2%;The population burden factor increase one percentage point,the premium rate will need to increase accordingly 0.14%;hospitalization expenses reimbursement ratio increased by one percentage point,the premium rate need increase 0.07%.

Second,based on the mathematical model,use the statistical experience data,evaluate the practice of our“Income determines expenditure”financial balance model.According to the empirical analysis,it is found that in practice,the medical insurance system of urban workers in our country is based on the principle of“Income determines expenditure”,will create a high excess burden and a distorting rate.Seemingly the premium rate rela tively stable behind,in fact,hidden in dependence on payment base response to the growth of expenditure;behind the basically stable of medical service prices,hidden high rate of hospitalization;payment policy is simple and extensive,set too low;based on“Income determines expenditure”,there is a blindly frequent adjustment to improve medical insurance treatment,so that the medical insurance fund bear its heavy and other issues.

Third,use the basic principles“financing and treatment are combined”and the relevant policy requirements in“13 th Five-Year Plan”to verify the feasibility,scientificity and practicability of the mechanism of financing and treatment of social medical insurance constructed in this paper. From the case of fertility insurance merge into medical insurance,it can be seen that the so-called fairness of financing is mainly due to the equal payment obligation between the same paid population,and the government's responsibility lies in providing subsidy for those who cannot afford payment. From the perspective of financing and treatment,solve the burden of high medical expenses mainly depends on multi-level health insurance sharing mechanism.

Based on the theory and multiple quantitative analysis,this paper argues that at present,the principle of“Income determines expenditure”is not in line with the inherent laws and basic theoretical requirements of the social medical insurance system,and there are also higher excess burden,distorted rate mechanism in practice;in the single control fee thinking,easily lead to hospitalization rate is high;treatment adjustment lack of scientific basis and unified standards and other issues. Based on the analysis of longterm actuarial balance,this paper also finds that the payment policy of basic medical insurance for urban workers in China under the short-term annual balance of payments mechanism,neglects its important role,and needs to adopt scientific method to set up.

Based on the above research,this paper suggests that China's social medical insurance system should be fully shifted to“Expenditure determines Income”with the policy and regulations are gradually improved,the system construction is becoming more and more perfect,the system operation is gradually standardized,the information system functions are continuously completed,and the large-scale scientific and technological means are increasingly developed. Specifically,should be defined from the scientific treatment of appropriate medical standards,improve the integrity of the credit system to standardize the base,the scientific uniform set the payment of the standard,to strengthen the government's commitment to low-income people,improve the multi-level health care system coordination and so on,further perfecting the construction of social medical insurance system in China.According to the model of the mechanism of financing and treatment,this paper can easily understand and understand the inherent law of social health insurance financing and treatment. The model is also the essence of social medical insurance system construction.In addition,another contribution of this paper is,based on the concept of actuarial balance of life cycle,the formula of determining the minimum payment period of science is designed,Its principle is similar to the pension payment schedule,can be used to improve the current basic insurance for urban workers in China the minimum payment of the standard set,with a strong policy innovation value and practical value.

Limited by author's capacity,this paper does not discuss the details of the policy application level,such as the management system,the legal environment,the risk of the mechanism and the specific operational measures.The explanation of the connotation,function and meaning of the model of the associated mechanism is relatively simple. The research methods used are relatively simple,which are subject to further research.In addition,the data used in this paper mainly by the“Jin Bao Engineering”,although I carefully screened,also fear inevitably loss of the whole,the conclusion is only responsible for the sample.

Key words:Social Medical Insurance,Financing,Treatment,Association Mechanism