医保预付制改革对医院行为和医疗费用的影响研究——基于单病种定额付费的改革

The Impact of Medical Prospective Payment Reform on Hospital Behavior and Expenses:A Study Based on Single Disease Quota Payment Reform

全面推行以按病种付费为主的多元复合型支付方式改革是现阶段深化医改的重要任务之一。本文使用中国某副省级城市2014—2019年住院患者的数据,通过双重差分方法分析了2018年按病种付费改革对医院行为和医疗费用的影响。实证结果表明,此次预付制支付方式改革使得所覆盖的101种疾病的次均住院费用显著下降3.8%(约530元),自付费用显著下降14.4%(约230元),在一定程度上控制了医疗费用的增长,降低了患者的医疗负担。但是,试点医疗机构在财务压力下存在调整患者结构的行为,并且对非试点医院产生了溢出效应。医疗机构的策略性行为还包括改变临床路径以达到继续进行按项目付费的目的,结果显示单病种定额付费实施之后,做手术概率下降4%,合并症诊断概率增加3%。因此,政府在推进医疗保险支付方式改革过程中,应该注重规范医疗机构的行为,加强对医疗服务质量的监督管理。

One of the important tasks of deepening medical reform is to comprehensively carry out the reform of composite payment methods based on payment by disease.Using the data of inpatients in a sub provincial city in China from 2014 to 2019 and the DID method,this paper analyzes the impact of Single Disease Quota Payment(SDQP) reform in 2018 on the behavior of medical institutions and medical expenses.The empirical results show that the payment reform has significantly reduced the average medical expense for inpatients of the 101 diseases covered by SDQP by 3.8%(about 530 RMB),and out-of-pocket expenses reduced significantly by 14.4%(about 230 RMB),which has slowed down the growth of medical expenses to a certain extent,and reduced the medical burden on patients.However,the pilot medical institutions have the behavior of adjusting patient structure under financial pressure,and have spillover effects in non-pilot hospitals.The strategic behavior of medical institutions also includes changing the clinical path in order to keep to be reimbursed by traditional Fee-For-Service program,for the probability of surgery decreased by 4% and the probability of complications increased by 3% after the implementation of SDQP.Thus,in the process of promoting the reform of medical insurance payment mode,the government should focus on standardizing the behavior of medical institutions and strengthening the supervision and management of medical quality.