总额预付制下县域医共体激励约束机制分析:个人利益与集体利益的冲突

A Study on Incentive-constraint Mechanism of Medical Alliances in County under Global Budget Payment:A Conflict of Interest between Individual and Collective

县域医共体是我国探索构建协同整合医疗卫生服务体系的重要实践形式之一,总额预付制是调和医共体内部利益矛盾、解决集体行动困境的核心政策工具。本研究提出县域医共体激励约束机制的分析框架及其理想化属性,并结合县域医共体典型案例,探讨县域医共体内部个人利益与集体利益冲突的原因,如具有较强信息优势与控制力的行动者在政策制定过程中发挥作用相对较弱,医共体内部信息对称性、博弈的公平性有待提升,同时现实中的医保结余对集体行动激励作用较弱,医保支付价、薪酬等配套政策工具对于引导个体行为与集体目标相一致的作用也相对有限等。建议进一步完善多元主体参与的良性协商与沟通机制,推动医务人员等具有较强信息优势与控制力的行动主体参与医保资金使用的决策过程;促进医疗医保医药协同发展与治理,建立以协商与准入为核心的医保支付价形成机制;基于公开、平等的谈判与协商机制,建立更加科学的预付总额核定机制与风险分担机制;建立信息披露机制与“村医”守门人制度等。

In order to explore the way of construction of integrated health care system, Medical Alliances in County is one of the most important practice model in China. Global budget payment has became the core policy tool to establish the incentive-constraint mechanism to integrate the interest of stakeholders. This paper discussed how to use the policy tool of global budget payment to establish an ideal incentive-constraint mechanism of medical alliances in county. Through the analysis of reform case, this paper found some problem : the stakeholders,who had strong information advantage and control, played a limited role in policy making and other parts of policy process;incentive effect should be improved, which is based on insurance balance, the medical and health service price of insurance,remuneration.It is suggested to further improve the benign consultation and communication mechanism with multiple stakeholders, and strengthen the participation of stakeholders with strong information advantages and control, such as medical staff of other member units other than the lead hospital. Deepening the “Tripartite Medical System”reform, we will establish a pricing mechanism for medical insurance with consultation and market access, and strengthen the incentive role of medical and health service income. Based on the open and equal negotiation and consultation mechanism, a more scientific global budget and risk sharing mechanism should be established to provide benign incentives.And establish the information disclosure system and gatekeeper system.