公立医院何以响应医保监管?——基于G省L市S医院的案例分析

How do Public Hospitals Respond to Medical Insurance Regulation?——Based on the Case Analysis of S Hospital in L City in G province

公立医院如何在医保监管下实现高质量发展是当前医疗体制改革进程中的重要议题。基于新制度理论,运用“制度环境—组织合法性—行为响应”的分析框架对L市某三甲公立医院展开个案分析,聚焦医保监管与医院响应行为以及二者之间交互关系的研究,发现面对我国医保监管不断深化,公立医院积极响应监管,其监管行为包括执行政策与规范管理、对接内部绩效考核体系、传导问责压力、推进智能化与信息化管理等,不同响应行为背后是公立医院行政导向、专业导向及市场导向之间的互动交叠。具体而言,公立医院政策执行和费用控制的响应行为更注重对行政导向和专业导向合法性的认同;服务效率与医疗质量提升的响应行为更倾向对专业导向和市场导向合法性的追求。公立医院多重导向的交叠会导致医保监管政策的执行与医疗技术发展、医疗质量提升之间存在一定程度的张力和冲突,但仍然从不同维度体现了医疗服务的公益性。

How to develop public hospitals with high quality under the pressure of medical insurance regulation is a major issue facing the current medical reform. Based on the neo-institutional theory, we conduct a case study of a Grade-three public hospital in L City, by using the “institutional environment—organizational legitimacy—behavioral response”analysis framework, focusing on medical insurance regulation and the hospital response behavior, as well as the interactive relationship between them. The study shows that with the constantly deepening of medical insurance regulation in China, public hospitals actively responded to the supervision by implementing policies and standardized management, connecting with internal performance evaluation system,conducting accountability pressure, promoting intelligent and information management and so on. The logic underlying the different response behaviors are the interaction between the administrative-orientation, professional-orientation and market-orientation of public hospitals. Specifically, the response behavior of public hospital policy implementation and cost control pays more attention to the recognition of administrative-oriented and professional-oriented legitimacy. The response behavior of hospital service efficiency and medical quality improvement is more inclined to the pursuit of professional-oriented and market-oriented legitimacy. The overlapping of multiple orientations of public hospitals will lead to a certain degree of tension and conflict between the implementation of medical insurance regulatory policies, the development of medical technology and the improvement of medical quality, but it still reflects the public welfare of medical services from different dimensions.