在社会生产力尚不足够发达，物质财富尚不足够丰富的社会主义初级阶段，如何在公平合理地筹资的同时尽可能给予国民充足的保障，解决健康筹资与待遇需求之间的矛盾，是完善中国特色社会医疗保险制度建设的核心议题。

本书所讲筹资与待遇的关联机制，主要是从宏观层面分析社会医疗保险制度基金财务的平衡机制。从筹资与待遇的关联机制看，社会医疗保险基金的财务年度平衡机制有以收定支、以支定收两种基本模式。以收定支，是根据所能筹集的资金收入确定支出规模，其特点是预算编制不产生赤字，以利于控制支出成本。以支定收与以收定支恰好相反，其基本原理是根据支出需求规模筹集所需资金。

对社会医疗保险制度来说，理论上，保费核定是基于风险评估预测的结果，“以支定收”是保险制度的内在规律。但是，实践中，我国城镇职工基本医疗保险制度却宣称“以收定支”为基本原则。两种收支平衡原则到底有何不同？中国城镇职工基本医疗保险制度为什么要宣称“以收定支”为基本原则？其实践效果到底如何？中国的社会医疗保险有无可能以及有无必要转向“以支定收”的财务平衡模式？表面上看来，这些问题似乎无关紧要，然而，如果循着不同路径去实践，则会产生不同的实践效果，有些施政方向甚至是悬殊极大，不仅关系到两种不同的建制理念、筹资理念和管理服务理念，还关系到我国社会医疗保险制度建设的福利成本，更关系到社会医疗保险制度的待遇水平的确定以及制度的长期可持续发展，实则是社会医疗保险制度建设的核心问题。

为了从理论上厘清“以收定支”和“以支定收”两种社会医疗保险财务平衡原则的基本内涵、缘起和具体的测算方法，比较分析二者的异同，厘清有关基本概念，更好地指导社会医疗保险财务预算编制工作，本书梳理了我国社会医疗制度的基本概念、制度特点和主要功能，从理论和实践相结合的比较视角，研究分析了以收定支和以支定收财务平衡方法的异同，并从收支关联的视角，构建适用于我国社会医疗保险政策环境的筹资与待遇关联机制模型，用以分析和揭示我国社会医疗保险基金财务平衡的内在本质规律。

通过本书的研究发现，社会医疗保险筹资与待遇是一个事物的两个方面，二者同寓于制度建设之中，相互支撑、互相关联、缺一不可。若将二者割裂，循着不同的路径，可能会产生截然不同的效果。所谓社会医疗保险筹资与待遇关联机制，其实质是制度覆盖人口结构及其健康状况、医疗消费服务价格和待遇保障水平综合作用的结果，是参与要素此消彼长的互动关系。在筹资与待遇关联机制模型中，缴费基数与费率成反比，人口负担系数、住院率、次均费用与岗平工资之比、报销比例与费率成正比。以支定收是社会医疗保险财务平衡的本质规律，而以收定支的政策实践必然存在诸多问题。

基于本书构建的关联模型，主要开展了三个层面的定量分析研究：

一是构建筹资与待遇关联机制数理模型，并在模拟现实政策环境下，验证和揭示社会医疗保险筹资和待遇关联机制各内生要素之间的数量关系。譬如，在既定的假设条件下，住院率每提升1个百分点，费率则需相应提升0.29%；次均住院费用相对于岗平工资每提升1个百分点，则相对应地需带动费率提升0.2%；人口负担系数每增加1个百分点，费率则需相应提升0.14%；次均住院费用报销比例提升1个百分点，则需费率上升0.07%。

二是基于所构建的数理模型，代入统计经验数据，对实践中我国“以收定支”的财务平衡模式进行政策实践效果的评估。经实证分析发现：实践中，我国城镇职工医疗保险制度宣贯“以收定支”为基本原则，不仅存在高额的超额负担和费率扭曲（G省2005—2015年的11年间，城镇职工基本医疗保险制度累计征收了约34.29%的超额负担，平均每年约2.09%的费率扭曲，费率的扭曲系数约占名义费率的23.73%），且看似相对稳定的费率的背后，其实隐藏着依赖费基应对支出增长的玄机；在医疗服务价格基本平稳的背后，暗藏着不断高企的住院率；缴费年限政策简单粗放、设置过低；在以收定支的指导原则下，事实上存在盲目频繁调整提高医保待遇，致医保基金不堪其重等问题。

三是应用筹资与待遇关联的基本原理，结合当前国家“十三五”规划改革的有关政策要求进行案例应用研究，以验证本书所构建的社会医疗保险筹资与待遇关联机制的可行性、科学性、实用性。从生育并入医疗保险的案例测算中可以看出，所谓筹资的公平性，主要在于同等缴费人群之间均等缴费义务；而政府责任在于为无力缴费人提供补助。从筹资与待遇关联的视角来看，解决高额医疗费用的负担，主要依托多层次的医疗保障分担机制。

基于理论研究和多重定量分析研究，本书认为，目前我国社会医疗保险制度“以收定支”原则既不符合社会医疗保险制度自身内在的发展规律和基本理论要求，在实践中也存在较高的超额负担、扭曲的费率机制；在单项控费思维下，极易导致住院率虚高；待遇调整缺乏科学依据和统一标准等问题。基于长期精算平衡的分析，本书还发现，我国城镇职工基本医疗保险的缴费年限政策在短期的年度收支平衡机制下，忽视了其重要的作用，亟待进一步采取科学的办法统一设置。

综合上述研究，本书建议，在政策法规逐步完善、制度建设日趋健全、制度运行逐步规范、信息系统功能不断完备，以及大数据等科技手段日益发达的今天，我国社会医疗保险制度应全面转向“以支定收”的财务平衡模式。具体应从科学界定医保待遇适度标准，完善收入诚信体系规范缴费基数，科学统一设置缴费年限标准，加强政府对低收入者的配资责任，完善多层次医疗保障制度的协同性等方面，进一步完善我国社会医疗保险制度建设。依循本书所构建的筹资与待遇关联机制模型，可简易操作、便捷理解社会医疗保险筹资与待遇关联的内在规律，其模型也是社会医疗保险制度建设的本质内涵。此外，本书的另一大贡献是，基于生命周期精算平衡的理念，设计了科学的最低缴费年限确定公式，其原理类似于养老金的计发月数表，可用于统一完善当前我国城镇职工基本医疗保险的最低缴费的设置标准，具有极强的政策创新价值和现实应用价值。

能力所限，本书并没有就“以支定收”型社会医疗保险基金财务平衡的管理体制、法制环境、机制风险以及具体的可操作措施等政策应用层面展开具体讨论和细节研究；对所构建关联机制模型的内涵、功能及意义的解释不足；所使用的研究方法也相对比较简单，这些均有待后期进一步加强研究。此外，本书所用数据主要由金保工程系统数据经由统计分析提取，虽由本人小心甄别，亦恐难免有失周全，有关结论，仅对样本负责。

关键词：社会医疗保险 筹资 待遇 关联机制

In the primary stage of socialism, where social productive forces are not developed enough and material wealth is not rich enough, how to provide adequate protection to the people as much as possible while raising funds fairly and reasonably, and solve the contradiction between health financing and treatment needs, is the core issue of improving the construction of the social medical insurance system with Chinese characteristics. The correlation mechanism between financing and treatment discussed in this book mainly analyzes the financial balance mechanism of the social medical insurance system fund from the macro level. From the perspective of the mechanism of financing and treatment, the financial year balance mechanism of the social medical insurance fund has two basic modes: revenue and expenditure and expenditure. Revenue and expenditure are determined according to the income of funds that can be raised, and the characteristic is that budgeting does not generate deficits, which is conducive to controlling expenditure costs. Expenditure is the opposite of expenditure and expenditure is based on the basic principle of raising the required funds according to the scale of expenditure needs. For the social medical insurance system, in theory, the premium approval is based on the results of risk assessment and prediction, and "income is determined by expenditure" is the inherent law of the insurance system. However, in practice, China's basic medical insurance system for urban workers claims that "revenue and expenditure" are the basic principle. What is the difference between the two break-even principles? Why does China's basic medical insurance system for urban workers claim that "revenue and expenditure" are the basic principle? What is the practical effect? Is it possible and necessary for China's social health insurance to shift to a "income-based" financial balance model? On the surface, these problems seem to be irrelevant, but if they follow different paths to practice, they will produce different practical effects, and some administrative directions are even very different, which is not only related to two different institutional concepts, financing concepts and management service concepts, but also related to the welfare cost of the construction of China's social medical insurance system, and more related to the determination of the treatment level of the social medical insurance system and the long-term sustainable development of the system, which is actually the core issue of the construction of the social medical insurance system. In order to theoretically clarify the basic connotation, origin and specific measurement methods of the two social medical insurance financial balance principles of "revenue to determine expenditure" and "expenditure to determine income", compare and analyze the similarities and differences between the two, clarify the relevant basic concepts, and better guide the preparation of social medical insurance financial budget, this book sorts out the basic concepts, institutional characteristics and main functions of China's social medical system, and studies and analyzes the similarities and differences between the financial balance methods of revenue and expenditure from the comparative perspective of combining theory and practice. From the perspective of income and expenditure linkage, a model of financing and treatment linkage mechanism suitable for China's social medical insurance policy environment is constructed, so as to analyze and reveal the intrinsic law of the financial balance of China's social medical insurance fund. Through the research of this book, it is found that the financing and treatment of social medical insurance are two aspects of the same thing, and the two are embedded in the construction of the system, supporting each other, interrelated, and indispensable. If you separate the two and follow different paths, it may have very different effects. The so-called social medical insurance financing and treatment linkage mechanism is essentially the result of the comprehensive effect of the system covering the population structure and its health status, medical consumption service prices and treatment guarantee levels, and is the interactive relationship between the participating factors and the other. In the model of the linkage mechanism between financing and treatment, the contribution base is inversely proportional to the rate, and the population burden coefficient, hospitalization rate, the ratio of the average cost to the average salary, and the reimbursement ratio are directly proportional to the rate. Determining income by expenditure is the essential law of the financial balance of social medical insurance, and there are bound to be many problems in the policy practice of determining expenditure by revenue. Based on the association model constructed in this book, three levels of quantitative analysis and research are mainly carried out: first, the mathematical model of the financing and treatment association mechanism is constructed, and the quantitative relationship between the endogenous elements of the social medical insurance financing and treatment association mechanism is verified and revealed in the simulated real policy environment. For example, under the given assumption, for every 1 percentage point increase in hospitalization rate, the rate needs to increase by 0.29%; For every 1 percentage point increase in the average hospitalization cost compared with the average salary, the corresponding rate needs to be increased by 0.2%; For every 1 percentage point increase in the population burden coefficient, the rate needs to be increased by 0.14%; If the average hospitalization expense reimbursement ratio increases by 1 percentage point, the required rate will increase by 0.07%. Second, based on the constructed mathematical model, substitute statistical experience data, and evaluate the practical effect of policy practice on China's financial balance model of "revenue and expenditure". After empirical analysis, it is found that: in practice, China's urban employee medical insurance system promotes the basic principle of "revenue and expenditure", not only has a high excess burden and rate distortion (in the 11 years from 2005 to 2015 in Province G, the basic medical insurance system for urban employees collected a cumulative excess burden of about 34.29%, an average annual rate distortion of about 2.09%, and the distortion coefficient of the rate accounted for about 23.73% of the nominal rate), and behind the seemingly relatively stable rate, In fact, there is a hidden mystery in relying on the fee base to cope with the increase in spending; Behind the basically stable price of medical services, there is a rising hospitalization rate; The payment period policy is simple and extensive, and the setting is too low; Under the guiding principle of determining expenditure by revenue, in fact, there are problems such as blind and frequent adjustment and improvement of medical insurance treatment, resulting in overwhelmed medical insurance funds. The third is to apply the basic principles of the association between financing and treatment, and carry out case application research in combination with the relevant policy requirements of the current national "13th Five-Year Plan" reform to verify the feasibility, scientificity and practicality of the social medical insurance financing and treatment association mechanism constructed in this book. It can be seen from the case calculation of maternity integration into medical insurance that the so-called fairness of financing mainly lies in the equal payment obligation among the same contributors; The responsibility of the government lies in providing subsidies to those who cannot afford to pay. From the perspective of the relationship between financing and treatment, solving the burden of high medical expenses mainly relies on a multi-level medical security sharing mechanism. Based on theoretical research and multiple quantitative analysis research, this book argues that the current principle of "revenue and expenditure" in China's social medical insurance system does not conform to the inherent development law and basic theoretical requirements of the social medical insurance system itself, and there is also a high excess burden and distorted rate mechanism in practice. Under the thinking of single cost control, it is easy to lead to an inflated hospitalization rate; The adjustment of treatment lacks scientific basis and unified standards. Based on the analysis of long-term actuarial balance, this book also finds that the payment period policy of basic medical insurance for urban employees in China ignores its important role under the short-term annual balance mechanism, and it is urgent to further adopt scientific methods to set it uniformly. Based on the above research, this book suggests that today, with the gradual improvement of policies and regulations, the increasingly sound construction of systems, the gradual standardization of system operation, the continuous improvement of information system functions, and the increasingly developed scientific and technological means such as big data, China's social medical insurance system should comprehensively shift to the financial balance model of "income by expenditure". Specifically, we should further improve the construction of China's social medical insurance system from the aspects of scientifically defining appropriate standards for medical insurance treatment, improving the income creditworthiness system, standardizing the payment base, scientifically and uniformly setting standards for the number of years of payment, strengthening the government's responsibility for allocating funds to low-income people, and improving the synergy of the multi-level medical security system. Following the model of financing and treatment correlation mechanism constructed in this book, the internal law of the association between financing and treatment of social medical insurance can be easily operated and convenient, and its model is also the essential connotation of the construction of social medical insurance system. In addition, another major contribution of this book is that, based on the concept of life cycle actuarial balance, a scientific formula for determining the minimum payment period is designed, which is similar to the monthly table of pensions, which can be used to unify and improve the minimum payment standards of basic medical insurance for urban employees in China, which has strong policy innovation value and practical application value. Due to the limitation of ability, this book does not carry out specific discussions and detailed research on the management system, legal environment, mechanism risks and specific operational measures of the financial balance of the "income by expenditure" type social medical insurance fund. insufficient explanation of the connotation, function and significance of the constructed association mechanism model; The research methods used are also relatively simple, and these need to be further developed at a later stage. In addition, the data used in this book is mainly extracted by statistical analysis of the data of the financial insurance engineering system, although I have carefully screened it, it may inevitably be incomplete, and the relevant conclusions are only responsible for the sample. Keywords: social medical insurance, financing, treatment, correlation mechanism（AI翻译）