政府规制与标尺竞争:医保支付方式改革的治理路径分析

Government Regulation and Yardstick Competition: An Analysis of the Governance Path of Medical Insurance Payment Reform

医保支付方式改革是深化医疗卫生体制改革和落实"健康中国"战略宏伟目标的重要环节,是优化医疗卫生资源配置和提高医疗服务质量的重要杠杆。本文基于政府规制和标尺竞争理论,提出一个解释性分析框架,以Y市按疾病诊断相关分组(DRG)付费改革为例,尝试分析在国家治理能力和治理体系现代化背景下医保支付方式改革的治理路径,通过分析发现我国医保支付方式改革的治理路径主要有:价格规制与竞争激励、奖惩规制与比较成本。Y市DRG付费改革主要从确定标尺、比较成本、奖惩规制和竞争激励四个方面着手,实现了政府价格规制与医院竞争激励、政府奖惩规制与医院比较成本的有机结合,解决了医保支付方式改革中医疗服务定价困难和医疗服务质量降低的问题。未来我国DRG付费改革可以通过价格规制与竞争激励、奖惩规制与比较成本两种治理路径来激励医疗机构控制医疗成本、规范医疗服务行为,促进医疗机构之间的合理竞争、提高医疗服务质量。

Medical insurance payment is an important for deepening medical and health reform and implementing the grand goal of the"Healthy China"strategy.It is also an important lever for optimizing the allocation of medical and health resources and improving the quality of medical services.This article proposes an explanatory analytical framework based on government regulations and scale competition theory.Taking the payment reform of DRG in City Y as an example,this paper attempts to analyze the governance of medical insurance payment method reform in the context of modernization of national governance capabilities and governance system.It is found through analysis that the governance path of China’s medical insurance payment method reform mainly includes:price regulation and competition incentives,reward and punishment regulation and comparative costs.Payment reforms based on DGR mainly proceeded from the determination of scale,comparative cost,reward and punishment regulations and competition incentives,and realized the organic combination of government price regulation and hospital competition incentives and government reward and punishment regulations and hospital comparative costs.In the future,DRG payment reform needs to focus on incentives for medical institutions to control medical costs through price regulation and competitive incentives,reward and punishment regulations and comparative costs.It’s very important to regulate the behavior of medical services,promote reasonable competition among medical institutions,and improve the quality of medical services.