医药消费的“年底效应”——基本医保报销机制对参保者医药消费行为的影响  

December Effects of Medical Consumption—Public Health Insurance Compensation Mechanism on Medical Consumption Behavior

作　　者：王歆[1] 于新亮[1] 程远[2] 

机构地区：[1]南开大学金融学院,天津300071 [2]南开大学经济学院,天津300071

出　　处：《保险研究》2015年第8期116-127,共12页Insurance Studies

基　　金：教育部哲学社会科学研究重大课题攻关项目"老龄化对中国经济发展的影响及应对策略研究"(编号13JZD005);教育部人文社会科学重点研究基地重大项目"我国社会发展与民生保障战略研究"(编号13JJD840004)的资助

摘　　要：本文选用天津市城镇职工基本医保抽样数据实证检验了报销机制诱导参保者增加年底医药消费的道德风险:参保者前11个月医药消费总额超过707.92元时会增加年底医药消费,突破800元起付线;而后,在固定报销比例下,前11个月门诊消费总额越高的参保者,其年底医药消费金额越高,但达到2543元这一峰值后会相应降低;在不足5346.04元时参保者仍然会增加年底医药消费以用尽5500元报销额度。本文据此提出三个完善方案,并模拟展示不同中段免赔设置对医药消费行为、医保基金支出的影响。Using outpatient reimbursement sampling data of Tianjin Basic Medical Insurance for Urban Workers from 2012 to 2014,we exponentially tested the phenomenon that the reimbursement mechanism induced the moral hazard of increased year-end medical consumption by participants to the Basic Medical Insurance. Participants would increase their medical expenditure to go beyond the 800 yuan threshold at the end of the year if their previous 11-month expenditure exceeded 707.92 yuan. Then, under a constant reimbursement percentage, the higher the first 11-month medical expenditure, the higher the year-end medical expense would be until reaching the peak level of 2543 yuan. If the medical expenditure was less than 5346.04 yuan within a certain year,the participant would also increase their year-end expenditure to use up the 5500 yuan reimbursement limit. We then proposed three types of plans accordingly, and by simulation showed the effects of different sets of middle-deductible design on medical con- sumption behavior and public health insurance fund expenditure.

关 键 词：报销机制 医药消费 道德风险 医保基金 面板门槛模型 

分 类 号：F840.684[经济管理—保险]