基于GMCR-ANP的按病种付费支付方式的冲突研究

Research on Conflicts of Disease-Based Payment System Based on GMCR-ANP

目的探讨解决按病种付费支付方式下各决策者的利益冲突,推动我国医保支付制度改革。方法立足利益相关者理论,描述按病种付费支付方式下的利益冲突主体,借助网络层次分析法计算得到各冲突方的策略权重排序,最终构建GMCR-ANP模型,寻求按病种付费方式下各利益主体博弈的均衡解,以模拟和预测冲突事态的发展过程及结果。结果在政府规范医保报销制度、严格考察各方医保费用使用情况下,医疗保险机构会严格控制医保费用,进而医疗服务提供者会放弃盲目逐利,参保者也会规范就医行为,避免盲目消费,此时政府会加大医保基金投入,最终达到平衡各方利益冲突的均衡状态。结论按病种付费要想取得长远发展,离不开各利益相关者的协同治理。对此,参保者应加强认知,避免盲目消费;医疗服务提供者应加强成本控制意识,规范医疗服务行为;医疗保险机构应严格控制医保费用,提升医保基金监管能力;政府应规范医保报销制度,加大医保基金投入。

Objective To explore the conflicts of interest of decision makers under the payment system of disease-based payment in order to promote the reform of China’s medical insurance payment system. Methods Based on Stakeholder Theory,describing the subject of conflict of interest under the disease-based payment system,using the Analytic Network Process(ANP) to calculate the ranking of the strategy weights of each conflicting party.Finally,the GMCR-ANP model is constructed to seek a balanced solution of the various stakeholders in the disease-based payment system to simulate and predict the development process and outcome of conflict situations.Results Under the government’s standardization of medical insurance reimbursement system and strict examination of the use of medical insurance fees,medical insurance institutions will strictly control medical insurance costs. And then,medical service providers will give up blind profit,and the insured persons will regulate the behavior of medical treatment and avoid blind consumption. At this time,the government will increase the investment of the medical insurance fund,and finally reach a balanced state of balancing the conflicts of interests of all parties. Conclusion The disease-based payment system if want to achieve long-term development,the cooperative governance of stakeholders is indispensable. Therefore,insured persons should strengthen their cognitive and avoid blind consumption;medical service providers should strengthen their awareness of cost control and standardize medical service behavior;medical insurance institutions should strictly control medical insurance fees,and improve the supervision capacity of medical insurance funds;the government should standardize the medical insurance reimbursement system,and increase the investment in medical insurance funds.