让分级诊疗运转起来:一个平衡激励分析框架——基于A、B两地医改实践的考察

Making Grading Treatment Work: A Framework of Balanced Incentive Based on Two Medical Insurance Reform Cases

在传统的总额控制下的按项目付费机制的强激励和弱约束下,为获取更多医保基金,各级医院对医疗资源、患者资源和医保基金形成竞争。在医保机构合理控费意愿和能力较弱的情况下,上级医院凭借优质医疗资源和信息不对称形成了对患者资源和医保基金的竞争优势。各级医院组织分散,均提供同质化的医疗服务,导致它们重竞争、轻合作,难以实现分级诊疗,医疗资源浪费严重。文章从委托代理和激励理论视角,提出实现分级诊疗的平衡激励框架:在加强医保机构组织能力基础上,合并上下级医院,以有效性和经济性目标为引导,建构以"按项目付费机制"和"医保余额奖励机制"为核心的平衡激励框架,调节医院行为,促进医疗资源下沉、上下分工协作,实现分级诊疗。此外,外部竞争和定向财政补贴等补充机制可进一步促进分级诊疗。文章通过对A、B两地医改实践的案例进行比较分析,讨论和检验了上述观点。

Under the traditional medical insurance payment mechanism,hospitals at all levels compete for medical resources,patients and medical insurance funds.Due to the low ability of medical insurance institutions to control expenses,superior hospitals monopolize insurance funds by possessing high-quality medical resources and information asymmetry,they emphasize competition and neglect cooperation.Therefore,grading treatment failed.This study proposes a balanced incentive analytical framework:1.strengthen the organizational capacity of medical insurance institutions and merge superior and primary hospitals;and 2.build a balanced incentive framework based on the project-based payment and medical insurance reward mechanism.Then we can find that superior hospitals began to allocate medical resources to primary hospital in the same hospital group,and grading treatment achieved.In this regard,this study verified these views through the comparative analysis of two cases.