薪酬激励和医疗服务供给:一个真实努力实验

Payment Systems and Medical Service Provision: A Real Effort Experiment

本文设计了一个医疗框架的真实努力实验,并考察了固定工资、按人头支付和按服务支付三种基本薪酬支付方式下的医疗服务供给行为。在此基础上设计了质量考核和框架效应两种新的薪酬激励制度并检验了其效果,还对比了非医学被试和医学被试的行为以探讨职业规范的影响。实验结果表明,首先,医生面临治疗数量和治疗质量之间的两难权衡:与固定工资相比,按人头支付和按服务支付能显著提升医生的治疗数量,但按人头支付会导致严重的治疗不足,按服务支付会导致严重的过度治疗;其次,引入质量考核能显著降低医生的过度治疗与治疗不足问题,其中损失框架下医生的表现更好;最后,职业规范的积极影响随着薪酬激励和职业规范两难冲突的缓解而削弱。

Payment systems not only affect physicians provision of medical services but also influence the efficiency and quality of those services.Therefore,establishing a fair and reasonable payment system can have far-reaching influence on the medical market and its reform.As policymakers may not fully anticipate the effect of payment system changes and policy changes may affect people s behavior in undesirable ways(Hennig-Schmidt et al.,2011),an analysis of the effect of payment incentives on medical service provision and physician behavior would have high referential value for the formulation of remuneration schemes(Brosig-Koch et al.,2017).In this field,abundant results have been achieved in recent years through experimental methods.This paper designed a real effort experiment within a medical framework to simulate a scenario between physicians and patients.Based on the framework,we examined the effects of payment methods,quality inspection,the framing effect,and professional norms on physician behavior.The core task of the experiment is to correct mistakes in blood test results:subjects were required to correct digital reports according to their printed versions.Typical treatment provision behaviors,including correct treatment,overtreatment,and undertreatment were defined.We examined three common payment systems—fee-for-service,capitation,and fixed salary—and introduced quality inspection on them.We tested the framing effect to see whether the loss frame under quality inspection improves physician service provision.Finally,medical and non-medical students were recruited to investigate the effect of professional norms.Results indicate that physicians face a quantity-quality trade-off—the dilemma between increasing the treatment amount and improving treatment quality.Compared with fixed salary,capitation and fee-for-service can increase the provision of medical service,but capitation induces undertreatment and fee-for-service induces overtreatment,all resulting in a significant reduction in treatment quality.Under fee-for-service,physicians may even intentionally provide harmful treatments that may cause severe tension between doctor and patient.Second,quality inspection can remarkably improve the quality of treatment.The results demonstrate that although quality inspection may reduce the number of treatments,both treatment accuracy and patient health condition are improved under all payment methods.The loss frame is better than the gain frame because all indicators of physician performance are better under the loss frame.Finally,the positive effect of professional norms is mitigated by the conflict between payment incentives and professional norms.Medical students perform significantly better than non-medical students in all aspects when there is a fierce conflict between compensation incentive and professional norms.Once the conflict eases,there is no difference between them.However,professional norms only alleviate,not eliminate,inappropriate incentives created by payment methods.This study contributes to the related research in the following aspects.First,we designed a real effort experimental task under a medical framework.By requiring participants to correct blood reports,a decision-making framework similar to a real medical environment was simulated in the laboratory.Second,we verified that introducing quality inspection on existing payment systems can effectively improve physicians medical service provision.We also inspected the effect of framing in the context of physician compensation incentives for the first time.Third,medical and non-medical students were recruited to investigate the effects of professional norms.Finally,the findings of this paper have practical significance.We find that the balance between quality and quantity is the main concern in the design of compensation schemes.Over-emphasis on quantity is an inappropriate incentive that may generate moral conflicts.Quality inspection can effectively improve medical service provision,and the loss frame works better.Professional norms can alleviate conflicts between doctors and patients to some extent,but they cannot completely solve the problems caused by incentive systems.Therefore,a reform of payment systems is necessary.