两保合一对医疗费用的影响:基于单一支付者制度的视角

The Impact of Insurance Consolidation on Medical Expenditures:Perspective from Single-payer System

本文利用2009~2015年全国公立医院财务报表数据,通过新农合与城居保合并发生的时间先后,来识别保险合并对医疗费用的影响。两保合一时,新农合与城居保的基金池合并,医保经办机构统一并成为地级市层面的单一管理者。本文发现两保合一使医保买方市场势力增强,赫芬达尔指数上升,进而医院收入下降3.6%,次均医疗费用下降2.9%,总诊疗量无显著变化,医院收入下降主要是次均药品费用下降带来的。若改革前地级市的赫芬达尔指数越小,则其买方市场势力增幅越大,控费效应越明显。而且对于市场份额更大的医院,两保合一的控费效应更小,这代表医保与医院的相对市场势力共同影响医疗费用。但本文也发现控费效果是短期的,而且病人自付费用占比提高,说明医院诱导了自费费用。

Using the 2009-2015 national public hospital financial data,this article identified the causal effects of insurance consolidation on medical expenditures by exploiting timing variation of Urban-Rural Health Insurance Integration in China.The merger of two social health insurances(NCMS and URBMS)consolidated the two health insurance funds and relevant administration authority,and formed a monopoly buyer of medical services at the prefecture level.The paper found that the merger increased the market power,thus reduced the hospitals’revenue by 3.6%,per capita medical expenditure by 2.9%,without influencing the volume of services.The decrease of revenue was mainly attributed to the decrease of per capita drug expenditure.The city with a lower HHI of insurance before the consolidation experienced a larger increase of HHI,thus a larger expenditure reduction.Moreover,the hospital with a larger market share experienced a milder expenditure reduction.The above two facts indicated that the relative bargaining power between insurances and hospitals influences the medical expenditures.However,the consolidation didn’t have long-term effect.Besides,the proportion of out-of-pocket expenditure rised,indicating hospitals might induce patients to use more out-of-pocket services.