Analysis of health insurance reform strategies from a risk-sharing perspective based on the Markov model  

风险共担视角下医保制度改革策略分析——基于马尔可夫模型

作　　者：XU Pengyu ZHAO Lindu 徐鹏宇;赵林度(东南大学经济管理学院,南京211189)

机构地区：[1]School of Economics and Management,Southeast University,Nanjing 211189,China

出　　处：《Journal of Southeast University(English Edition)》2025年第1期118-126,共9页东南大学学报(英文版)

基　　金：The National Natural Science Foundation of China(No.72071042)。

摘　　要：China’s healthcare system faces increasing challenges,including surging medical costs,resource allocation imbalances favoring large hospitals,and ineffective referral mechanisms.The lack of a unified strategy integrating standardized coverage with personalized payment compounds these issues.To this end,this study proposes a risk-sharing reform strategy that combines equal coverage for the same disease(ECSD)with an individualized out-of-pocket(I-OOP)model.Specifically,the study employs a Markov model to capture patient transitions across health states and care levels.The findings show that ECSD and I-OOP enhance equity by standardizing disease coverage while tailoring costs to patient income and facility type.This approach alleviates demand on high-tier hospitals,promoting primary care utilization and enabling balanced resource distribution.The study’s findings provide a reference for policymakers and healthcare administrators by presenting a scalable framework that is aligned with China’s development goals with the aim of fostering an efficient,sustainable healthcare system that is adaptable to regional needs.中国的医疗体系面临着不断升级的挑战,包括医疗费用激增、资源分配失衡、偏向大医院以及转诊机制失效,由于缺乏将标准化保障与个性化支付相结合的统一战略,这些问题变得更加复杂。本研究提出了一种将同病同保障(ECSD)与差异化自付(I-OOP)模式相结合的风险共担医保改革策略。采用马尔可夫模型捕捉病人在不同健康状态和护理级别之间的转变。研究结果表明,同病同保障和差异化自付模式通过标准化疾病覆盖范围来提高公平性,同时根据患者收入和医疗机构类型调整费用成本。该方法减轻了大医院的需求压力,促进了基层卫生服务利用率,并实现了更均衡的资源分配。该研究提出了一个与中国发展目标相一致的可扩展框架,为政策制定者和医疗管理者提供了参考,以促进建立一个适应区域需求的高效、可持续的医疗体系。

关 键 词：equal coverage for the same disease(ECSD) individualized out-of-pocket(I-OOP) health insurance reform risk sharing Markov model 

分 类 号：C913.7[经济管理] F842.684[社会学] R197.1[医药卫生—卫生事业管理]