医药分开改革中的供方行为:基于医保住院赔付记录的分析

Supply-side Responses to Zero Markup Drug Policy: Evidence from Inpatient Claims Data

本文基于某市2015-2016两年的医保住院赔付记录,利用断点回归设计评估医药分开改革的效果。结果显示,医药分开改革显著降低了药品费用,改变了住院费用的构成,但未能降低单次住院总费用。这一结果是由供方主导的,在不同级别的医院间具有异质性。级别越高的医院,收入越不依赖于药费,药费降幅也越大,应对改革的策略也越灵活。此外,本文还发现改革的效果随时间变化:在改革实施后的五个月内,有明确的政策目标要求的药费和材料费继续下降,无明确政策目标要求的检查费在三级医院显著上升。这些结论表明,在行政市场化模式下,设定了硬性约束的改革是能够实现其政策目标的,但也容易造成新的扭曲,尤其是对于那些已经取得了足够谈判力量的供给主体。

In 2015,the State Council of the People’s Republic of China launched a comprehensive reform of urban public hospitals,explicitly requiring them to abolish the drug markup,which has long been an important source of hospital revenue.Drawing on inpatient reimbursement records from a large city in 2015 and 2016,this paper uses a regression discontinuity design(RDD)to evaluate the effects of the Zero Markup Drug Policy(ZMDP).The results show that ZMDP significantly reduces drug spending and alters the composition of hospitalisation costs,but it fails to reduce the total inpatient expenditure.Further analysis reveals that these results are primarily driven by the supplier and they are heterogeneous by hospital level.In this context,higher-level hospitals are less dependent on drug revenues and are therefore able to adopt more flexible strategies in response to ZMDP,hence their drug revenues are reduced more.The effects of the reform are also found to vary over time.Expenditure on strictly regulated drugs and materials continue declining within five months of the implementation of the ZMDP,while testing costs without a clear policy restriction began to increase significantly in tertiary hospitals.These conclusions indicate that,under the administrative marketisation model,reforms that establish hard constraints may achieve their policy objectives,but they are also likely to cause further distortions,especially for supply entities that have already obtained sufficient bargaining power.