公立医院医保费用管理博弈分析和策略选择  

The game analysis and strategy choice of medical insurance expense management in public hospitals

作　　者：邹志辉[1] 张源 吴洋[1] 赖永洪[1] ZOU Zhi-hui;ZHANG Yuan;WU Yang;LAI Yong-hong(The Third Affiliated Hospital of Guangzhou Medical University,Guangzhou Guangdong 510515,China;Jiangmen Central Hospital,Jiangmen Guangdong 529030,China)

机构地区：[1]广州医科大学附属第三医院,广东广州510150 [2]江门市中心医院,广东江门529030

出　　处：《卫生软科学》2021年第7期71-74,共4页Soft Science of Health

摘　　要：[目的]在医保支付方式改革背景下提出医院医保费用管理的策略与建议。[方法]通过医、保、患三方利益主体的博弈分析,对医院医保费用的管理进行探讨。[结果]保、患双方博弈容易形成保方通过保障诱导需求和保障约束供给的"保患合谋"。医方虚应守约的额外收益和受到保方严格监管的处罚损失、保方严格监管的成本和宽松监管遭受的损失这4个因素是决定和影响医、保双方博弈均衡的关键。要使患方有较高的基本医疗服务保障率,保方要严格监管,减少医方违约利得,医方也需增强文化软实力建设,提高社会信誉利得。[结论]公立医院医保费用管理关键是以医保费用支付效果为抓手,做好医保费用管理开源与节流策略才能实现医、保、患三方共赢。Objective Under the background of the reform of medical insurance payment mode,this paper puts forward the strategies and suggestions of hospital medical insurance expense management.Methods Through the game analysis of the three stakeholders of medical insurance,hospital and patients,this paper discussed the problems of medical insurance cost management in hospitals.Results The game between the insurance and the patient was likely to form a"collusion of insurance and patients"in which the insurance induced demand and restricts the supply through guarantees.The additional income of the doctor’s compliance and the penalty loss of the insured’s strict supervision,the cost of strict supervision and the loss of loose supervision,these four factors were the key to determined and influenced the game equilibrium between the medical and insurance both sides.In order to make higher security rate of basic medical service for the patients,it was necessary for the insurance to ask strict supervision and decrease of the profits from breach of contract of the medical party;the medical party also needed to strengthen the construction of cultural soft power and improve the social reputation profits.Conclusions The key of medical insurance cost management in public hospitals is to take the payment effect of medical insurance cost as the starting point,and do a good job in the open source and reduce expenditure strategy of medical insurance cost management,so as to achieve tripartite benefit situation among hospitals,insurance and patients.

关 键 词：公立医院 医保费用管理 博弈 策略 

分 类 号：R197.3[医药卫生—卫生事业管理]