市级统筹、制度设计与医保控费  

City-level Pooling,Policy Design and Fee Containment by Social Healthcare Insurance Scheme

作　　者：付明卫[1,2] 王普鹤 赵嘉珩 朱恒鹏 FU Ming-wei;WANG Pu-he;ZHAO Jia-heng;ZHU Heng-peng

机构地区：[1]中国社会科学院经济研究所 [2]中国社会科学院民营经济研究中心 [3]中国社会科学院大学经济学院

出　　处：《产业经济评论》2020年第6期53-69,共17页Review of Industrial Economics

基　　金：国家社会科学基金一般项目“我国医院行业市场机制有效性的实证研究”(批准号:17BGL170)的阶段性成果。

摘　　要：提高基本医疗保险统筹层次是深化中国基本医疗保障制度改革的重大任务。然而,提高医保统筹层次可能加重医保经办人员监管上的道德风险行为,导致医药费用上涨。统筹层次提高后能否通过相关制度设计控制医药费上涨呢?本文利用A市城职保市级统筹提供的自然实验,使用断点回归设计方法,经验研究发现市级统筹通过良好的制度设计能控制医药费用上涨。具体而言,市级统筹后患者总费用、患者自付费用、医保基金支付费用都没有增加;费用没有增加的原因在于良好的制度设计遏制了医疗机构通过延长患者住院时间来增加收入的行为,限制了患者涌向三级医院就医的倾向。这一结论对于参数估计模型中不同的多项式次数、不同带宽都成立,在考虑了政策实施前后的干扰因素、季节性因素后依然成立,在使用非参数估计时依然成立。这些制度设计的控费效果不受医疗机构距离市级医保机构远近的影响。基于本文发现,做实市级统筹,应在医保基金出险责任分担、区县经办人员人事管理、参保人就医管理等制度建设上下功夫。To upgrade the pooling level is a major task in deepening the reform of China’s basic medical insurance system.However,improving the pooling level may worsen moral hazard problem of supervisors,and thus leads to an increase in medical expenses.This paper uses the natural experiment provided by the practice of improving the pooling level of Urban Employee Based Medical Insurance in City A,and employs Regression Discontinuity Design to empirically study the impact of the upgrading practice on medical expenses and expenditure by medical insurance fund.It is found that,due to good policy design,improving from county-level to city-level doesn’t drive up medical expenses.Specifically,the total patient expenses,patient out-of-pocket expenses,and medical insurance fund payment doesn’t increase after the reform;the reason lies in that good policy design has curbed the behavior of hospital to increase income by extending the patient’s hospital stay,and has limited the tendency of patients to flock to tertiary hospitals for medical treatment.This conclusion remains for different polynomial orders and different bandwidths in the parametric estimation model,after considering the interference factors and seasonal factors before and after the reform,and when using non-parametric estimation.The containment effect of these system designs is not affected by the distance between hospital and municipal medical insurance bureaucracy.Based on these findings,to consolidate the city-level pooling reform nationwide,efforts should be made in the policy design on risk-sharing of medical insurance expenditure,personnel management of county-level supervision staff,and patient’s hospital choice.

关 键 词：医疗保险 市级统筹 道德风险 医药费用 

分 类 号：F842.684[经济管理—保险] R197.1[医药卫生—卫生事业管理] D922.182.3[医药卫生—公共卫生与预防医学]