医疗保险支付方式改革与医药费用控制  

Medical Insurance Payment Method Reform and the Control of Medical and Drug Expenditures

作　　者：瞿婷婷 解乃琪 易沛 Qu Tingting;Xie Naiqi;Yi Pei(Social Security Research Center,Sun Yat-sen University,Guangzhou 510275,China;Lingnan College,Sun Yat-sen University,Guangzhou 510275,China;School of Insurance,Guangdong University of Finance,Guangzhou 510521,China)

机构地区：[1]中山大学社会保障研究中心,510275 [2]中山大学岭南学院,510275 [3]广东金融学院保险学院,510521

出　　处：《南开经济研究》2019年第5期145-162,共18页Nankai Economic Studies

摘　　要：为了控制医药费用的不合理增长,我国自2011年起正式推行基本医疗保险总额控制支付方式。本文采用2013—2014年广东省多个地市基本医疗保险参保人的微观数据,建立倍差法模型,定量评估了此项改革的控费效果,分析了具体的影响机制。结果表明,给定其他因素不变的条件下,改革没有显著降低住院医药费用,但使医保付费降低了5.76%,使患者付费提高了7.01%。改革对一级医院的控费效果符合政策目标,对三级医院的控费效果则不尽理想,这与三级医院的医保付费限额偏低有关。为了从医疗保险获得足额的付费,并规避年终清算的超支风险,三级医院在不同药品之间、不同医疗项目之间以及医药之间将目录内或报销比例较高的医药项目(西药、中成药)替换为目录外或报销比例较低的医药项目(中草药、检查、手术、化验)向患者转移医药费用,同时将较低和较高的医保付费分别分配在年初和年末。上述结果对不同的样本期、控制组均稳健成立。本文为未来我国医疗保险支付方式改革提供了重要的经验参考。To control the rapid growth of medical and drug expenditures,China has formally implemented global budget payment method since 2011.This paper constructs a difference-indifference model with 2013—2014 panel data of basic medical insurance(BMI)participants from multiple cities in Guangdong to empirically evaluate effects of such reform on inpatient expenditure.It is found that ceteris paribus,the reform did not significantly decrease quarterly total inpatient expenditure,among which BMI payment was significantly reduced by 5.76%while out-of-pocket spending was significantly increased by 7.01%.It is also found that the reform goal was achieved at primary hospitals not tertiary ones,which may be driven by the case that tertiary hospitals were assigned with too low budget ceiling.In order to obtain BMI payment as much as possible and to avoid deficit risk prior to year-end settlement,tertiary hospitals substituted BMI-covered or high reimbursement rate services(Western and Chinese patent drugs)with BMI-not-covered or low reimbursement rate ones(herbal drugs,examinations,surgeries,chemical tests)to transfer expenditures to patients by switching among drugs,services and between.Hospitals also allocated low and high BMI payment at early and subsequent quarters in a year,respectively.These results are robust to different sample periods and control groups.This paper helps to inspire meaningful empirical references for China′s future basic medical insurance payment method reform.

关 键 词：基本医疗保险 总额控制 医疗费用 药品费用 倍差法 

分 类 号：F42[经济管理—产业经济]