总额预付制医疗保险支付方式改革对医疗费用的影响:基于断点回归设计

Impact of the Reform of the Prospective Payment System on Medical Expenses:Based on Regression Discontinuity Design

2012年11月14日,《关于开展基本医疗保险付费总额控制的意见》颁布,总额预付制医疗保险支付方式改革在各地试点全面展开。总额预付制改革如何影响医疗费用支出?本文以某省级职工医疗保险2013年总额预付制改革为例,利用精确断点回归方法分析改革在医疗费用方面的实际效果。研究结果显示,一方面,总额预付制显著降低了统筹基金支付的医疗费用,在节约医疗保险统筹基金方面起到了良好的效果;另一方面,个人支付的医疗费用有所上升,其中重症病种、罕见病种和重度病种较为明显。因此,应当降低个人自付比例,探索将总额预付制与按疾病诊断组付费制(DRGs)等相结合的支付方式,引导医疗保险支付方式向精细化、科学化方向发展,以减轻个人的医疗费用负担。

On November 14,2012,the"Opinions of the Ministry of Human Resources and Social Security,the Ministry of Finance,and the Ministry of Health on the control of the total payment of Basic Medical Insurance" was promulgated,and the reform of Prospective Payment System(PPS)has been carried out in pilot areas.How does the reform of PPS affect medical expensesTaking the PPS reform implemented by the employee medical insurance scheme at the provincial level in 2013 as an example,this paper analyzes the effect of the reform on containing medical expenses by using the sharp regression discontinuity method.The results show that PPS has significantly reduced the medical expenses paid by the social pooling component of the medical insurance;meanwhile,the out-of-pocket payments have increased,especially for patients with severe or rare diseases.Thus,it is necessary to reduce the proportion of individual out-of-pocket payments,and explore the payment method that combines PPS and Diagnosis Related Groups(DRGs),improve the payment method in a refined and scientific way,and finally further reduce the burden of medical expenses for individuals.