At present, both the “unified income and expenditure” and “adjustment fund” system of the basic medical insurance provincial planning need to clarify the relationship between "structure risk" and "management risk". Based on international experience, this paper proposes to construct the provincial pooling risk regulation plan suitable for the situation of China. First, the "structure risk" is separated by the age, gender, health status and other characteristics of insured patients. The second plan is to establish a standardized risk expenditure model, and give the "standard" fund expenditure formula of each pooling area based on structure risk adjustment, in order to separate the "management risk". The process above is demonstrated by further using the medical insurance settlement data of a sample province from 2013 to 2019, and it is found that the scheme is operable and feasible. It is suggested that in the process of promoting provincial pooling, the structure risk of fund expenditure should be separated from the management risk, and the structure risk should be coordinated and the management risk should be compacted. At the same time, regional realities should be considered to prevent reverse allocation of funds and ensure fairness of the system.
Key words
provincial pooling /
risk regulation /
structural risk /
management risk
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