医保药品支付标准与采购价的差额产生机制及其归属问题研究

An analysis on formation mechanism and balance affiliation between health insurance payment standard and market price

本文分析了不同医保支付标准制定政策下差额的形成机制,发现差额产生机制除与药品的报销比例有关外,主要取决于支付标准的制定方向和参考价格体系来源的选择。在差额归属问题上,结合重庆、绍兴等试点城市的具体做法探讨由医疗机构留作内部发展模式和由政府部门统筹后按绩效重新分配模式的优劣性,认为与简单的差额自留模式相比,差额上交再分配模式可以在保留医疗机构议价积极性的同时规范医疗机构的行为,提升医疗机构服务水平。为避免差额上交再分配模式存在医疗机构假报数据私留差额的政策风险,从博弈论的视角分析医疗机构与监管部门的策略选择,以探讨模式的可行性。最后,就差额归属问题提出"三步走"政策建议,即短期内将差额留归医疗机构以提高其议价积极性,同时积极探索差额上交再分配模式的绩效考核及监管方式,长期则通过建立健全市场价格调查及医保支付标准调整机制,逐步消除差额。

At present,because market price survey and health insurance payment standard adjustment mechanism in china is incomplete,health insurance payment standard can not be completely equivalent to the actual market price of drugs.This paper analyzed and summarized the main factors affecting the balance and formation mechanisms under different medical insurance payment standard policies.It is found that the balance formation mechanism depends not only on the reimbursement ratio of drugs,but also on the development pattern of the payment standard and on the source of the reference price system selected.On the issue of the ownership of the balance,from the specific practices of pilot cities such as Chongqing and Shaoxing,it can be seen that the merits and demerits still exist to the medical institutions for internal development models or re-allocated by the government agencies performance-based.Compared with the simple balance retention model,the redistribution model can enhance the service of medical institutions by regulating their behavior.However,medical institutions may provide false data to get more balance in the redistribution model,and game theory was used to reduce the policy risk of misreporting the private balance of data from medical institutions,and the analysis of strategic choices of medical institutions and supervisory departments Finally,“three-step”policy proposal was proposed on the issue of balance attribution.In the short term,the balance should be given to the medical institutions to increase their bargaining motivation.At the same time,the performance appraisal and supervision methods should be explored to enhance the feasibility of redistribution model.In the long run,the balance should be eliminated gradually through the improvement of market price survey and medical insurance payment standard adjustment mechanism.