差异化报销比例设计能够助推分级诊疗吗?——来自住院赔付数据的证据

Does Differentiated Reimbursement Rate Help to Promote Hierarchical Medical Services: Evidence from Inpatient Claim Data

本文以某市(1)2013年新农合补偿政策调整为自然实验,使用住院赔付数据探讨了医保差异化报销比例设计对患者就医层级选择的影响。双重差分结果表明:县级医院报销比例提高5个百分点,能够引导住院患者去往县内而不是县外三级医院就医的概率增加0.5%~0.8%。安慰剂测试和更换对照组测试都表明了这一效果的稳健。报销比例效应在不同病种和年龄群体上呈现出较强的异质性,平均花费较低疾病的患者,以及少年、中年和低龄老年患者的就医行为更容易受到政策影响。但在上述各项情形中,政策变动所产生的效应都不足以抵消城镇化等自然趋势所引发的就医向上集中。这一结果表明,在分级诊疗中,需方报销政策尽管能够发挥作用,但总体影响程度有限,在进行更加精细化、有针对性的医保制度设计的同时还需要供方改革的支持。

This paper studied how differentiated reimbursement rates affected patients＇ hospital choice. Using a set of NCMS claim data from a city in China,the result of difference-in-difference model showed that a 5 percentage points rise of the reimbursement rate for level-2（ county level） hospitals led to a 0. 5% to 0. 8% increase of probability for choosing hospitals located within the county boundary instead of a level-3 hospital outside of the county.Both placebo test and test using alternative control groups verified its robustness. Low-cost diseases and juvenile,middle aged and low-level elderly age groups were more affected. However,for all the above mentioned situations,this policy change effect was likely to be offset by the natural trend such as urbanization. This showed that in the hierarchical medical system,reimbursement policy could play a role,but to a limited extent. More supply-side reforms are needed in a more fine-tuned medical insurance system design.