医疗保险谈判机制理论基础及政策设计

Theory Base and Policy Sesign for Health Insurance Negotiation Mechanism

实践的依据在于理论,文章首先筛选出帕累托最优以及契约论等与医疗保险谈判机制相关的理论,接着探讨各理论对医保谈判机制的贡献及应用。其中,帕累托最优应用:通过责权利的重新规范完全可以实现帕累托改进,达到帕累托最优。契约论应用:医疗保险协议也可以称之为医疗保险契约,协议管理是医保谈判的初级阶段形式,可以明确主体、客体和内容等法律关系。最后,提出医疗保险谈判机制构建对策:借鉴国际经验,结合我国医保改革的阶段及我国国情特点,从系统、组织、个体三个层面提出相应对策和建议。系统层面,做好顶层设计,"准确定位,锁定目标"、经由"科学设计"、"战略控制",确保目标"执行到位";组织层面,医保机构要更新观念、引入竞争,而医疗机构也要重新定位,并且力量要整合,谈判意识和动力要提高;个体层面,控制医生的道德风险,加强参保者在医保谈判中的参与度,进行参保者教育是主要措施。

Practice is usually based on the theory practice.In this article, some theories were selected to be described, such as Pareto optimality theory and contract theory on health insurance.Then the contribution and application on health insur- ance negotiation mechanism were analyzed. Pareto optimality theory：the re-specification to duty-power-benefit could a- chieve Pareto improvement to Pareto optimal.Firstly, the health insurance agreement could also he called the health insur- ance contract.The agreement management was the initial stage of health insurance negotiations.Then we could know legal re- lations with the subject, object and content. At last, countermeasures to construction of health insurance negotiations were promoted. Learning from international experience, under the background of health reform in our country and our national conditions, corresponding countermeasures and suggestions was put forward from three levels among the system, organization and individual level.On the system level, a good top-level design includes ＂precise positioning, targeted＂ ,＂ scientific design ＂ ,＂ strategic control＂ ,＂ the implementation of place＂ .On the organizational level, medical insurance providers need to intro- duce new ideas and more competition, and medical institutions also need to be re-position, integration and increase negotia- tion ability and motivation.On the individual level,the moral hazard of medical practitioners must he controlled and enroll- ment rate of insured persons should be enhanced in the negotiations besides that the insured person should accept the main measure of education.