市场结构、医疗保险与医疗费用的关系研究

Relations on market structure, health insurance and medical expenses

本文构建了全民医保环境下由一家基层医院和一家综合医院组成的两级医疗服务系统。应用两层决策模型研究不同医疗市场结构下医疗保险对医疗服务价格和医疗总费用的影响,最后进行了数值模拟,对医保报销比例和患者选择偏好进行敏感性分析。研究发现:医疗总费用比率报销模式要优于医疗服务量补贴模式;当医疗供给方具备定价能力时,医疗保险的引入会导致医疗服务价格的上升和社会医疗总费用的增加;而医疗竞争市场能在一定程度上遏制医疗保险带来的医疗价格膨胀效应,但受到患者选择偏好的影响。因此,要重视建立分级医疗体系,提高基层医院医疗服务能力和服务水平,对于不同层级医院的医保报销病例进行严格规定,并实施严格的审查监督制度,才能真正提高医保资金的使用效率,切实帮助患者减轻医疗负担。

After the universal medical insurance system was established in China,patient’s self-paying ratio about medical expense has been decreasing,but absolute expenses for total amount and self-paying part have been increasing.This paper investigates how medical insurance impacts service price and total cost in different market structures by analyzing a two-echelon medical service chain composed of one primary hospital and one general hospital.The purpose of this paper is to analyze three models:(1)decentralized decision model with a subsidy for medical expenses;(2)centralized decision model based on the maximum benefit of medical group with a subsidy for medical expenses;and(3)centralized decision model of medical group with a subsidy for medical services.Firstly,to support two hospitals with different levels based on the patient’s preference and different proportions of reimbursement,a two-phase game model is set up by using the game theory to characterize the choices of medical insurance organization and hospitals.Every hospital tries to maximize their total revenue.Medical insurance organizations aim to minimize the total medical expense.The first layer of the model is to solve the object-minimization problem of medical insurance organizations.The second layer is the Nash Equilibrium in hospitals competition.The results show that the volume of hospitals is irrelevant to the rate of reimbursement.The medical demand increases as two hospitals increase price for their medical services at the time.The rate of reimbursement and patient’s preference have a great influence on the price of medical services.In addition,the decision of the medical group is analyzed by using the two-phase game mode in which the decisions are centralized to maximize performance for the entire service system.It shows that the patient’s preference has different effects on the medical price of the general hospital in different market conditions.The medical services price of primary hospital increases as the rate of reimbursement increases in both competitive and monopoly markets.The total health expenses of two hospitals also increase as the rate of reimbursement of the primary hospital increases in both competitive and monopoly markets.The total health expenses of two hospitals decrease in the competitive market,but increase in the monopoly market as patients prefer primary hospital.Thirdly,the subsidy for medical services by medical group is analyzed and compared to the subsidy for medical expenses,under the equal levels of financial compensation.This translates into higher health expense and higher volume of medical services.The result shows that the cost subsidy is much better than the workload subsidy.Finally,a numerical example is presented for comparison of these two market models.The example shows that the medical group could attract more patients in the primary hospital,but will result in more insurance fund.Compared with the competitive market,the medical group will set the higher medical health price and provide less service.As the reimbursement ratio rises,it will increase medical service cost and total medical expense of the whole society in competitive and monopoly markets,and the effect is more significant in the medical group market.Sensitive analysis shows that medical price and total medical expense will decrease in the competitive market and will increase in the monopoly market as patients prefer primary hospitals.In summary,the health insurance would cause health care price inflation and offset the effect of health insurance if the hospital has market power.Moreover,the effect will be weakened in a competitive market but influenced by patients’preferences on primary hospital.The findings are supported with the gradual increase of average hospitalization expenses over the past ten years according to China health Statistics Annuals.The issue is more serious with the county-level medical institutions.In order to relieve patients’burden effectively and improve the efficiency of medical insurance,it should be cautious to promote medical group unless in poor sanitation areas.As the medical service quality is the major influential factor of seeking medical care,great efforts should be made to improve the service provided by community-based medical and health care facilities.A more scientific classification system of medical services should be established and the reimbursement of medical expenses of diseases at different hospitals should be strictly regulated.This will reduce health care cost and increase the service efficiency of health insurance fund.