医疗保险支付方式改革对医疗费用的影响及其作用机制——来自A市医保按病种分值付费的证据  

Impact of the Reform of Medical Insurance Payment Methods on Medical Costs and Impact Mechanism:Evidence from City A’s Diagnosis-Intervention Packet Payment

作　　者：何文 朱艺唯 申曙光[2] He Wen;Zhu Yiwei;Shen Shuguang

机构地区：[1]湖南大学公共管理学院 [2]中山大学岭南学院

出　　处：《金融经济学研究》2025年第1期94-108,共15页Financial Economics Research

基　　金：国家自然科学基金项目(72204079);国家社会科学基金重大项目(21&ZD125)。

摘　　要：基于A市医疗保险大型微观报销数据,在准实验的分析框架下,运用事件研究法分析按病种分值付费这一新兴医保支付方式对医疗费用的影响及作用机制。实证结果表明,医院为了适应新的费用补偿机制,会主动控制每一诊次的住院费用,因此实施按病种分值付费后,单次住院费用显著降低了6.3%。为获得更多的分值,医院具有明显的分解住院次数和高套分值的道德风险,具体表现为住院总次数和次均住院病种分值在政策实施后反而显著提高了3.4%和14.0%,从而导致住院总费用居高不下。总体而言,不同级别医院在支付政策变更后的行为具有一致性,其中三级医院的反应程度更大。基于此,建议相关部门以价值为导向改革医保支付方式,提高医保精细化管理水平,从而实现患者、医院和医保基金利益的统一。Using the large-scale micro-reimbursement data on medical insurance in City A,this study used event study methodology to analyze the impact of an emerging medical insurance payment method called diagnosis-intervention packet(DIP)on medical costs and the corresponding impact mechanism under the framework of quasi-natural experiment analysis.Empirical results showed that hospitals would actively control the medical costs per inpatient case to adapt to the new cost compensation mechanism.Therefore,the medical costs per inpatient case were significantly reduced by 6.3% after the implementation of DIP.To obtain higher scores,hospitals have obvious moral hazards in decomposing the number of hospitalizations and conducting up-coding.Specifically,the total number of hospitalizations and average DIP score of inpatients increased significantly by 3.4% and 14.0%,respectively,after the new payment policy was implemented,which resulted in the total hospitalization costs remaining high.In general,the behavior of hospitals at different levels after the payment policy changed was consistent,with tertiary hospitals being more responsive.These results indicate that relevant departments should reform medical insurance payment methods in a value-oriented manner and improve the level of refined management of medical insurance to unify the interests of patients,hospitals,and medical insurance funds.

关 键 词：医疗保险 支付方式 医疗费用 道德风险 按病种分值付费 

分 类 号：C812[社会学—统计学]