基于委托代理理论的我国医院门诊医保支付方式博弈分析  

Game analysis on hospital outpatient payment methods of Chinese basic health insurance based on principle-agent theory

作　　者：吴琼[1] 刘月辉[2] 刘丽华[2] 马晓静[1] Wu Qiong;Liu Yuehui;Liu Lihua;Ma Xiaojing(Institute of Medical Information/Medical Library,Chinese Academy of Medical Sciences and Peking Union Medical College,Beijing 100020,China)

机构地区：[1]中国医学科学院医学信息研究所,北京100020 [2]解放军总医院创新研究部医院管理研究所,北京100853

出　　处：《中华医院管理杂志》2023年第2期87-92,共6页Chinese Journal of Hospital Administration

基　　金：北京协和医学院中央高校基本科研业务费(3332021052)。

摘　　要：我国的基本医疗保险(以下简称医保)门诊支付方式仍以按项目付费为主,易导致医疗费用不合理增长。本研究采用委托代理理论,分析医保经办机构与医保定点医院之间的委托代理关系,构建门诊支付方式利益博弈模型和配套监管博弈模型,通过模型均衡解探索利益最优且均衡的医保支付方式及其监管机制,为推进我国医保门诊支付方式改革提供决策支持。门诊支付方式利益博弈模型分析结果显示,后付制与预付制相结合的混合制能够实现制度内总利益和各方利益最优和最大化,具体形式为采取按门诊病例组定额付费、按项目付费和按总额预算付费相结合的多元混合支付方式。通过监管博弈模型分析发现,要保障上述混合支付方式预期效用的实现,在监管时必须考量的要素包括医院不控费获得的不合理收入与控费获得的奖励之差、医院不合理收入被发现后的惩罚大小、监管成本大小以及政府和参保人群利益损失情况。建议医保定点医院门诊采取以按门诊病例组定额付费为主、按项目付费为辅加以按总额预算控制的混合制支付方式;医保经办机构可从完善处罚方式、降低监管成本、发挥政府行政权力和公众监督力量方面完善门诊医保监管机制。As the major means of outpatient payment for basic medical insurance(the insurance for short)relies on fee-for-service,it tends to encourage unreasonable growth of medical expenses.Based on the principal-agent theory,this paper analyzed the principal-agent relationship between the insurance handling agencies and the hospitals designated by the insurance,and constructed a benefit game model of outpatient payment methods and the supporting supervision game model.This practice aims to explore the optimal and balanced benefit of the insurance payment methods and supporting supervision mechanism,and provide decision support for promoting the reform of medical insurance outpatient payment in China.The analysis results of the benefit game model of payment methods showed that a system mixing the post-payment and pre-payment could optimize and maximize the total benefits and interests of all the stakeholders within the system.Specifically,the practice recommended was a mixed payment integrating ambulatory-payment-classification,fee-for-service and global-budget-payment.The analysis of the supporting regulatory game model found that the factors that must be considered to ensure the expected utility of the above mixed payment mode as follows:the gap between the unreasonable income obtained by the hospital by out-of-control charging and the reward obtained by under-control charging,the size of the penalty after the unreasonable income of the hospital was discovered,the size of the regulatory cost and the loss of benefits of the government and the insured group.It is suggested to adopt the mixed payment method mainly based on the ambulatory-payment-classification supported by fee-for-service and global-budget.At the same time,medical insurance agencies can improve their supervision mechanism from such aspects as perfecting penalties,reducing supervision costs,leveraging government administrative power and advocating public supervision.

关 键 词：基本医疗保险 门诊支付方式 医保监管 委托代理理论 博弈论 

分 类 号：R197.1[医药卫生—卫生事业管理]