医疗保险支付总额预算管理改革是否提高了医疗服务效率?--基于某省级职工医疗保险的证据  

Does the Total Budget Management Reform Improve the Efficiency of Medical Services? Evidence from a Provincial Employee Medical Insurance

作　　者：李诗晴[1] 褚福灵[1] LI Shiqing;CHU Fuling

机构地区：[1]中央财经大学保险学院,北京102206

出　　处：《济南大学学报（社会科学版）》2021年第3期140-150,160,共12页Journal of University of Jinan:Social Science Edition

基　　金：国家社会科学基金重大项目“医保费用科学分配及有效监控的技术方法研究”(项目编号:14AZD117)的阶段性成果。

摘　　要：2012年底,各地开始全面开展医疗保险支付总额预算管理的改革探索。2019年,全国97.5%的医疗保险统筹地区完成了总额预算管理改革。为验证总额预算管理改革是否提高了医疗服务效率,本文在建立医疗保险支付与医疗服务行为的经济学模型的基础上,以某省级职工医疗保险由按服务项目付费制向总额预算管理改革这一自然实验为研究对象,通过混合模型、静态个体效应面板模型和断点回归模型进行实证检验。研究结果表明,总额预算管理有效降低了整体的平均住院日,特别是降低了重度病种的平均住院日,且未导致住院人次整体下降的普遍拒诊患者的现象,也未引发轻病住院人次上升的诱导轻病住院行为,证明了总额预算管理在提高医疗服务效率方面总体上取得了良好的效果。但是单一的总额预算管理作为医疗保险支付方式并不完美,例如总额预算管理在一定程度上导致重度病种住院人次的下降,说明可能存在拒绝重度病种患者住院的现象。On November 14, 2012, "Opinions of the Ministry of Human Resources and Social Security, the Ministry of Finance, and the Ministry of Health on the Control of the Total Payment of Basic Medical Insurance" (Human and Social Ministry issued [2012] No. 70) was promulgated. All regions in China have since launched the Total Budget Management Reform for the payment of medical insurance. In 2019, 97.5% of the medical insurance coordinating areas across the country have completed the Total Budget Management Reform. In order to verify whether the Total Budget Management Reform has improved the efficiency of medical services, based on the theoretical analysis of relevant economics models, this paper takes the natural experiment of a provincial employee medical insurance changing from the Fee for Services System to the Total Budget Management Reform as the research object. Empirical tests are conducted through OLS mixed models, static individual effect panel models and regression discontinuity models. Results show that the Total Budget Management Reform does not lead to a general decline in hospitalizations, and does not cause an increase in hospitalizations for minor illnesses, and effectively reduces the overall average hospital stay, especially the average hospital stay for severe diseases. It proves that the Total Budget Management Reform has achieved good results in improving the efficiency of medical services. However, the Total Budget Management Reform alone is not perfect as a medical insurance payment method. For example, the Total Budget Management Reform has led to a decrease in the hospitalizations for severe diseases to a certain extent, indicating that patients with severe diseases might have been refused for hospitalization.

关 键 词：道德风险 医疗保险支付方式改革 总额预算管理 医疗服务效率 

分 类 号：C913.7[经济管理]