论医保控费的障碍及其克服

A study on the barriers to medicare fee control and its overcoming

医保控费不仅是医疗保险领域的核心问题,更是实现公民积极健康权的关键所在。医保控费的逻辑链条由"国家(医保费用支付方)-公民(患者)"之间的行政给付法律关系、"国家(医保费用支付方)-医院(医疗服务提供方)"之间的委托代理关系、"医院(医疗服务提供方)-公民(患者)"之间的医疗服务关系组成,相关主体在这三种关系中逐利倾向暗合是医保费用失控的根本成因。对此,目前的解决方案主要有支付方式改革和优化健康管理两条路径。前者虽有利于控费,却存在医疗服务提供方降低服务质量、推诿病患等缺陷;而通过后者整合资源、构建激励相容机制,可以在根本上实现医保控费和提高全民健康水平的双重目标。

The control of medical insurance expenses is not only a core issue in the medical insurance field,but also the key to achieve the right to health.The logical chain of medical insurance expense control consists of the legal relationship of administrative payment between the"State(medical insurance payer)and citizens(patients)",the principal-agent relationship between the"State(medical insurance payer)and hospitals(medical service provider)"and the medical service relationship between the"hospital(medical service provider)and citizens(patients)".In these three relationships,the underlying cause for the uncontrollability of medical insurance expenses is the tendency of relevant entities to seek benefits covertly.There are two solutions to this problem:reform of payment mode and optimization of health management.The former is beneficial to cost control,but it has the defects of lowering service quality and putting patients off.And by integrating resources and constructing incentive compatibility mechanism,the two goals of cost control of health insurance and raising the health level of the whole people can be achieved fundamentally by the latter.