医保支付激励与医生多任务执行偏差——新的解释框架和政策启示

Medical insurance payment incentive and doctor’s multi-tasking execution deviation:A new explanatory framework and policy implications

在"医保—医院—医生"的委托代理结构中医院并非直接的执行主体,而是依靠医生完成多种任务,医保支付方式对于医生的服务行为具有重要的激励作用。基于我国公立医院医疗服务供给存在自利"韧性",本文构建了以"三重机制"为特征的医保支付激励医生行为的分析框架,并以此为基础解释了随着收入激励和成本激励功能弱化、"压力—能力"失衡条件下问责约束以及容忍机制的生成,医生产生偏离政策预期的代理行为并获得制度空间的过程。因此,建议从构建医生收入预期和惩戒预期的角度继续完善有关薪酬、人事和财政制度,以使医生能更好地扮演好"守门人"的角色。

In theprincipal-agent structure of“medical insurance-hospital-doctor”,hospitals are not the immediateexecuting agents.Instead,theyrely on doctors to perform various tasks.The payment modelof medical insurance hasan important incentive effect on doctors’service behavior.Based on the fact thatself-interestsin the supply of medicalservices byChina’s public hospitals has high resilience,this paper constructeda frameworkfeaturing a“triple-mechanism”for analyzing how medical insurance payment model would motivate doctors’behaviors.Using this framework,our paperexplainedwhydoctors would have deviating-from-expectedagency behaviorsand obtain institutional spacealong withthe functional weakening of income incentives and cost incentives andthe generation of accountability constraints and tolerance mechanisms under the“pressure-competence”imbalance.Therefore,it is suggested that thecompensation,human resources,and financial systems should continue to be improved from the perspective of building up doctors’income and punishmentexpectations,so as to allow thedoctors to better serve their role as the“gatekeeper”.