医保支付方式改革如何减轻道德风险?--来自医保基金支出的证据

How to Reduce Moral Hazard in the Reform of Social Medical Insurance Payment?--Evidences from the Expenditure Data of Social Medical Insurance Fund

推进医保支付方式改革已成为我国下阶段基本医疗保障管理和深化医改的重要环节,是保障参保人员的健康效益和医保基金可持续发展的重要手段。本文利用某市医疗保险基金支出的数据,建立渐进双重差分模型,探究按人头付费的医保支付方式改革对医疗服务供给方道德风险的影响。结果表明:按人头付费确实能够显著降低城职保患者医疗费用和并发症数量,但对城居保患者无上述作用,说明按人头付费能够减轻医疗服务供给方的道德风险,但恰当的人头费用标准设定才能达到理想效果;药品费用是医疗服务供给方减轻道德风险的主要途径,治疗费用次之;患者就诊次数显著减少,且前往基层医疗机构就诊次数增加,促进分级诊疗进程的加快,同时改革过程中并未发现患者道德风险的证据;按人头付费改革效果并未随时间推移而减弱,反而以较为稳定的增幅增强,说明经济激励为医生提供有效的非药物治疗方案提供了充足的动力。

Promoting the reform of social medical insurance payment has become an important link in the next stage of basic medical security management and deepening medical reform in China,which is an important method to ensure the health care benefit of the insured and sustainable development of the social medical insurance fund.This paper used the expenditure data of social medical insurance fund in a certain city to establish a generalized difference-in-differences model to explore the influence of capitation on the moral hazard from medical service providers.The results are as follows.Firstly,capitation is able to reduce the medical expenditure and the number of complications of patients who are covered by Urban Employee Basic Medical Insurance Plan,but has no effect on the patients covered by Urban Resident Basic Medical Insurance Plan.The results suggest that capitation does reduce the moral hazard from medical service providers,but can only be achieved when the capitation standard is proper.Secondly,drug cost is the main way for medical service providers to cut down moral hazard,followed by treatment cost.Thirdly,the number of visits of patients decreases significantly,and the number of visits to primary medical institutions increases,which helps to accelerate the progress of graded diagnosis and treatment,and no evidence of patient moral hazard is found in the process of reform.Finally,instead of weakening over time,the capitation reform effects have increased steadily,suggesting that economic incentives provide sufficient motivation for doctors to provide effective non-pharmacological treatments.