芜湖市社会医疗保险道德风险及其防控研究
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摘要
近年来,社会医疗保险道德风险行为不断被媒体曝光,引起了社会的普遍关注。这些行为严重侵蚀社保基金并损害医疗保障体系公平,已经影响到医保制度的平稳运行,对其有效的控制与约束是保障基金安全和制度良性运行的前提。而由于医疗行为的高度专业性、医疗服务的异质性、医疗服务的需求弹性和医疗信息的高度不对称性,使得社会医疗保险道德风险行为具有相当的隐蔽性；医疗保险第三方付费方式,这种制度本身的设计缺限给医患双方都有利可图,骗保成本过低、医疗消费的伦理色彩以及医疗消费的不确定性,使得风险控制成为理论和实践操作上的难题。本文通过对芜湖市近年来医疗保险查处中得到违规案件,对医疗保险道德风险的表现进行了分类,分别从医疗保险供方、需方以及供需方合谋三个方面介绍了医疗保险道德风险主要表现形式,通过典型案例和数据进一步论证医疗保险领域道德风险的种种表现和特点,并揭示道德风险的产生的原因。笔者结合多年来从事医疗保险方面的工作经验,将综合运用经济学、管理学等学科的相关理论,着重从理论基础、医保制度因素、医院补偿因素、监管因素、道德因素、成本因素等方面对医疗保险道德风险的成因进行深入的剖析,最后从体制、法律规范、政策引导、技术、监管、道德等方面提出了防范医疗保险道德风险的建议。
In recent years, the issue of moral hazard in social medical insurance was frequently reported and covered via various medias, which attracted public general concern of the whole society. These immoral behaviors had seriously eroded social insurance fund, doing harm to the justice of medical security system and preventing the smooth operation of medical insurance system. Therefore, effective control and constraint on moral hazard are essential to safeguard medical fund safety and maintain benign operation of the system. However, due to the highly professionalness of medical treatment, heterogenicity and demand elasticity of medical service, and high asymmetry of medical information, the behavior of moral hazard in social medical insurance is easily concealed. Moreover, the third-party paying way of medical insurance, a design defect of the system itself, makes both medical staffs and patients obtain some illegal profit. Under such circumstance, the hazard control had become a touchy problem both theoretically and practically, because of the low cost of cheating in insurance, the moral features and uncertainty of medical consumption. The classification of moral hazard of medical insurance was conducted in this paper, based on illegal medical cases discovered in medical insurance of Wuhu city in recent years. Three kinds of moral hazard were introduced in this paper from the perspective of suppliers of medical insurance, demanders of medical insurance and conspiracy of suppliers and demanders. Furthermore, various representation and features of moral hazard in medical insurance were further verified through sample cases and data analysis, with reasons of their occurrence disclosed. In general, the causes of moral hazard of medical insurance were thoroughly analyzed mainly from the perspective of theoretical bases, medical insurance system, hospitals compensation, governing factors, moral factors and cost factors, by using related theory on economics, management science and other subjects, on the basis of the author's rich working experience on medical insurance. Finally, suggestions on preventing medical hazard in medical insurance were provided from many aspects:medical system, law and regulation, policy guidance, technology, supervision, and moral or ethics.
In recent years, the issue of moral hazard in social medical insurance was frequently reported and covered via various medias, which attracted public general concern of the whole society. These immoral behaviors had seriously eroded social insurance fund, doing harm to the justice of medical security system and preventing the smooth operation of medical insurance system. Therefore, effective control and constraint on moral hazard are essential to safeguard medical fund safety and maintain benign operation of the system. However, due to the highly professionalness of medical treatment, heterogenicity and demand elasticity of medical service, and high asymmetry of medical information, the behavior of moral hazard in social medical insurance is easily concealed. Moreover, the third-party paying way of medical insurance, a design defect of the system itself, makes both medical staffs and patients obtain some illegal profit. Under such circumstance, the hazard control had become a touchy problem both theoretically and practically, because of the low cost of cheating in insurance, the moral features and uncertainty of medical consumption. The classification of moral hazard of medical insurance was conducted in this paper, based on illegal medical cases discovered in medical insurance of Wuhu city in recent years. Three kinds of moral hazard were introduced in this paper from the perspective of suppliers of medical insurance, demanders of medical insurance and conspiracy of suppliers and demanders. Furthermore, various representation and features of moral hazard in medical insurance were further verified through sample cases and data analysis, with reasons of their occurrence disclosed. In general, the causes of moral hazard of medical insurance were thoroughly analyzed mainly from the perspective of theoretical bases, medical insurance system, hospitals compensation, governing factors, moral factors and cost factors, by using related theory on economics, management science and other subjects, on the basis of the author's rich working experience on medical insurance. Finally, suggestions on preventing medical hazard in medical insurance were provided from many aspects:medical system, law and regulation, policy guidance, technology, supervision, and moral or ethics.
引文
①约翰·伊特韦尔,默里·米尔盖特,彼得·纽曼新帕尔格雷夫经济学大辞典[M]第3卷,北京经济科学出版社,1992：588
Arrow, K. j., (1963), Uncertainty and the Welfare Economics of Medical Care, American Economic Review, 53, pp.942-973
②Pauly, Mark V. (1986), Taxation, Health Insurance and Market Failure in the Medical Economy, Journal of Economic Literature,24, June, pp.629-75
① Roemer,Milton I, "Bed Supply and Hospital Utilization:a National Experiment", Hospitals, vol35,1961, pp.988-933.
② Pauly M. V. (1968), The Economics of Moral Hazard:Comment, American Economics Review, Vol.58, pp.513-537
③ Evans R. G(1974), Supplier-induced demand, some empire evidence and implications pp.162-173.
①邓超,侯建明。“对医疗保险中道德风险及其约束机制的探讨”,《金融与经济》,2005(4)：35-37
②史文璧,黄丞。“道德风险与医疗保险风险控制”,《经济问题探索》,2005(2)：60-63
①李玮,黄丞,蒋馥。“社会医疗保险中道德风险问题的博弈分析”,《上海交通大学学报》,2004(3)：470-473
②李冰水、李玉娇。中国社会医疗保险中的道德风险及控制机制研究[J].广西经济管理干部学院学报,2010第4期
③胡苏云。“医疗保险中的道德风险分析,《中国卫生资源》,2000, (3)
④赵曼.中国劳动和社会保障发展研究报告[M].中国财政经济出版社,2002
⑤陈永升.医疗保险中医疗供方道德风险行为分析[J].新疆财经学院学报,2002第4期
⑥郑秉文.信息不对称与医疗保险[M].经济社会体制比较,2002第6期
①金春林.控制医疗费用的策略重点应着眼于宏观层面[J].中国卫生资源,2000第6期
②孟庆跃.医疗保险支付方式改革对费用控制的影响分析[M].卫生经济研究,2002第9期
③史文壁,黄丞,“道德风险与医疗保险风险控制”,《经济问题探索》,2005(2)：60-63
④王锦锦。论社会医疗保险中的道德风险及其制度消解”,《人口与经济》,2007(3)：62-66
⑤邓超,侯建明。“对医疗保险中道德风险及其约束机制的探讨”,《金融与经济》,2005(4)：35-37
⑥司选明.医疗保险道德风险防范问题探究[J].天津社会保险,2010第3期
⑦李延荣.基本医疗保险定点医疗机构道德风险防范对策[J].山东人力资源和社会保障,2011第5期
1.陈永升.医疗保险中医疗供方道德风险行为分析[J].新疆财经学院学报.2002.(4)
2.代志明、周浩杰.试论社会医疗保险中的道德风险及防范[J].卫生经济研究,2005.(5)
3.郭有德.医疗保险中道德风险的经济学分析[J].复旦学报.2011.(1)
4.胡苏云.医疗保险中的道德风险分析[J].中国卫生资源.2000.(3)
5.胡苏云.医疗服务和保险中公共机制和市场机制的作用[J].人口与经济.2000.(6)
6.姜新旺.黄劲松.社会医疗保险中医方道德风险的防范与控制[J].软科学.2005.(1)
7.金春林.控制医疗费用的策略重点应着眼于宏观层面[J].中国卫生资源.2000.(6)
8.刘潇.社会医疗保险道德风险及其控制机制研究[D].中国人民大学硕士论文.2008
9.李冰水、李玉娇.中国社会医疗保险中的道德风险及控制机制研究[J].广西经济管理干部学院学报.2010.(10)
10.李娟.我国社会医疗保险中的道德风险及其规避[D].湘潭大学硕士论文.2005
11.李婧.社会医疗保险中“医患合谋”的道德风险问题浅析[J].当代经济.2010.(10)
12.李翔.城镇居民医疗保险中道德风险的防范与控制[J].中国卫生事业管理.2011.(3)
13.李玮、黄垂、蒋馥.存在道德风险的我国基本医疗保险体系中各市场主体行为分析[M].预测.2003.(1)
14.李延荣.基本医疗保险定点医疗机构道德风险防范对策[J].山东.山东人力资源和社会保障.2011.(5)
15.林森.社会医疗保险的道德风险规避策略研究
16.林敏赵俊.基本医疗保险定点医疗机构道德风险及其防范对策[J].医学与社会.2010.(4)
17.刘伟娜.我国医疗保险市场上的道德风险及其控制[D].西北财经大学硕士论文.2007
18.刘晓婧.防范医疗保险中的医疗机构道德风险[J].卫生经济研究.2010.(5)
19.刘晔.医疗保险中道德风险问题的博弈分析及对策探讨[D].苏州大学硕士论文.2008
20.梁彦.社会医疗保险道德风险控制的经济学分析——从医疗服务的供需两方面入手[J].现代商贸工业.2009.(8)
21.路佳.社会医疗保险道德风险问题研究[D].河北大学硕士论文.2009
22.陆燕春.借鉴管理式医疗保险制度.有效控制医疗费用的快速增长[M].上海金融.2003
23.孟庆跃.医疗保险支付方式改革对费用控制的影响分析[M].卫生经济研究.2002.(9)
24.毛瑛、李娇凤.城镇职工基本医疗保险道德风险的防范研究[J].中国医学伦理学.2005.(8)
25.马蔚姝、张再生.医疗保险市场中骗保行为产生的经济学分析[J].现代经济探讨.2008.(11)
26.史文璧、黄丞.道德风险与医疗保险风险控制[J].经济问题探索.2005.(2)
27.仇雨临、孙树菡.医疗保险[M].中国人民大学出版社.2001.(3)
28.孙秀均.社会医疗保险中的道德风险及其控制策略[D].武汉大学硕士学位论文.2004
29.司选明.医疗保险道德风险防范问题探究[J].天津社会保险.2010.(3)
30.田家官.社会保险道德风险的发生机制及防治[J].财经科学.2010.(8)
31.王琦等.信息不对称条件下医生道德风险的防范[J].中国农村卫生事业管理.2005.(12)
32.王锦锦.论社会医疗保险中的道德风险及其制度消解[J].人口与经济.2007.(3)
33.王建.社会医疗保险中的道德风险与信任机制[J].北京科技大学学报.2008.(6)
34.王永其、陈吉林.做实个人账户促进医改上新台阶[J].中国卫生经济.2004.(11)
35.吴传俭.道德风险与我国社会医疗保险基金安全问题分析[J].中国卫生经济.2005.(11)
36.吴传俭.社会医疗保险道德风险博弈与防控措施研究[J].医学与哲学.2006.(7)
37.赵迪.我国社会医疗保险医方道德风险问题研究[J].商业经济.2010.(10)
38.赵曼.社会医疗保险费用约束机制与道德风险规避[J].财贸经济.2003.(2)
39.赵曼.中国劳动和社会保障发展研究报告[M].中国财政经济出版社.2002
40.赵小苏、王永其、宋余庆、王建宏.我国城镇职工基本医疗保险的道德风险及其防范[J].卫生经济研究.2001.(7)
41.郑秉文.信息不对称与医疗保险[M].经济社会体制比较.2002
42.保罗·J·费尔德斯坦.卫生保健经济学[M].北京.经济科学出版社.1998
43.约翰·伊特韦尔默里·米尔盖特、彼得·纽曼.新帕尔格雷夫经济学大辞典[M]第3卷.北京经济科学出版社,1992
44. Arrow, K. J. Uncertainty and the Welfare Economics of Medical Care, American Economic Review,53, pp.942-973
45. Pauly, Mark V. Taxation, Health Insurance and Market Failure in the Medical Economy, Journal of Economic Literature,24, June, pp.629-75
46. Evans R. G(1974), Supplier-induced demand, some empire evidence and implications pp.162-173.
Arrow, K. j., (1963), Uncertainty and the Welfare Economics of Medical Care, American Economic Review, 53, pp.942-973
②Pauly, Mark V. (1986), Taxation, Health Insurance and Market Failure in the Medical Economy, Journal of Economic Literature,24, June, pp.629-75
① Roemer,Milton I, "Bed Supply and Hospital Utilization:a National Experiment", Hospitals, vol35,1961, pp.988-933.
② Pauly M. V. (1968), The Economics of Moral Hazard:Comment, American Economics Review, Vol.58, pp.513-537
③ Evans R. G(1974), Supplier-induced demand, some empire evidence and implications pp.162-173.
①邓超,侯建明。“对医疗保险中道德风险及其约束机制的探讨”,《金融与经济》,2005(4)：35-37
②史文璧,黄丞。“道德风险与医疗保险风险控制”,《经济问题探索》,2005(2)：60-63
①李玮,黄丞,蒋馥。“社会医疗保险中道德风险问题的博弈分析”,《上海交通大学学报》,2004(3)：470-473
②李冰水、李玉娇。中国社会医疗保险中的道德风险及控制机制研究[J].广西经济管理干部学院学报,2010第4期
③胡苏云。“医疗保险中的道德风险分析,《中国卫生资源》,2000, (3)
④赵曼.中国劳动和社会保障发展研究报告[M].中国财政经济出版社,2002
⑤陈永升.医疗保险中医疗供方道德风险行为分析[J].新疆财经学院学报,2002第4期
⑥郑秉文.信息不对称与医疗保险[M].经济社会体制比较,2002第6期
①金春林.控制医疗费用的策略重点应着眼于宏观层面[J].中国卫生资源,2000第6期
②孟庆跃.医疗保险支付方式改革对费用控制的影响分析[M].卫生经济研究,2002第9期
③史文壁,黄丞,“道德风险与医疗保险风险控制”,《经济问题探索》,2005(2)：60-63
④王锦锦。论社会医疗保险中的道德风险及其制度消解”,《人口与经济》,2007(3)：62-66
⑤邓超,侯建明。“对医疗保险中道德风险及其约束机制的探讨”,《金融与经济》,2005(4)：35-37
⑥司选明.医疗保险道德风险防范问题探究[J].天津社会保险,2010第3期
⑦李延荣.基本医疗保险定点医疗机构道德风险防范对策[J].山东人力资源和社会保障,2011第5期
1.陈永升.医疗保险中医疗供方道德风险行为分析[J].新疆财经学院学报.2002.(4)
2.代志明、周浩杰.试论社会医疗保险中的道德风险及防范[J].卫生经济研究,2005.(5)
3.郭有德.医疗保险中道德风险的经济学分析[J].复旦学报.2011.(1)
4.胡苏云.医疗保险中的道德风险分析[J].中国卫生资源.2000.(3)
5.胡苏云.医疗服务和保险中公共机制和市场机制的作用[J].人口与经济.2000.(6)
6.姜新旺.黄劲松.社会医疗保险中医方道德风险的防范与控制[J].软科学.2005.(1)
7.金春林.控制医疗费用的策略重点应着眼于宏观层面[J].中国卫生资源.2000.(6)
8.刘潇.社会医疗保险道德风险及其控制机制研究[D].中国人民大学硕士论文.2008
9.李冰水、李玉娇.中国社会医疗保险中的道德风险及控制机制研究[J].广西经济管理干部学院学报.2010.(10)
10.李娟.我国社会医疗保险中的道德风险及其规避[D].湘潭大学硕士论文.2005
11.李婧.社会医疗保险中“医患合谋”的道德风险问题浅析[J].当代经济.2010.(10)
12.李翔.城镇居民医疗保险中道德风险的防范与控制[J].中国卫生事业管理.2011.(3)
13.李玮、黄垂、蒋馥.存在道德风险的我国基本医疗保险体系中各市场主体行为分析[M].预测.2003.(1)
14.李延荣.基本医疗保险定点医疗机构道德风险防范对策[J].山东.山东人力资源和社会保障.2011.(5)
15.林森.社会医疗保险的道德风险规避策略研究
16.林敏赵俊.基本医疗保险定点医疗机构道德风险及其防范对策[J].医学与社会.2010.(4)
17.刘伟娜.我国医疗保险市场上的道德风险及其控制[D].西北财经大学硕士论文.2007
18.刘晓婧.防范医疗保险中的医疗机构道德风险[J].卫生经济研究.2010.(5)
19.刘晔.医疗保险中道德风险问题的博弈分析及对策探讨[D].苏州大学硕士论文.2008
20.梁彦.社会医疗保险道德风险控制的经济学分析——从医疗服务的供需两方面入手[J].现代商贸工业.2009.(8)
21.路佳.社会医疗保险道德风险问题研究[D].河北大学硕士论文.2009
22.陆燕春.借鉴管理式医疗保险制度.有效控制医疗费用的快速增长[M].上海金融.2003
23.孟庆跃.医疗保险支付方式改革对费用控制的影响分析[M].卫生经济研究.2002.(9)
24.毛瑛、李娇凤.城镇职工基本医疗保险道德风险的防范研究[J].中国医学伦理学.2005.(8)
25.马蔚姝、张再生.医疗保险市场中骗保行为产生的经济学分析[J].现代经济探讨.2008.(11)
26.史文璧、黄丞.道德风险与医疗保险风险控制[J].经济问题探索.2005.(2)
27.仇雨临、孙树菡.医疗保险[M].中国人民大学出版社.2001.(3)
28.孙秀均.社会医疗保险中的道德风险及其控制策略[D].武汉大学硕士学位论文.2004
29.司选明.医疗保险道德风险防范问题探究[J].天津社会保险.2010.(3)
30.田家官.社会保险道德风险的发生机制及防治[J].财经科学.2010.(8)
31.王琦等.信息不对称条件下医生道德风险的防范[J].中国农村卫生事业管理.2005.(12)
32.王锦锦.论社会医疗保险中的道德风险及其制度消解[J].人口与经济.2007.(3)
33.王建.社会医疗保险中的道德风险与信任机制[J].北京科技大学学报.2008.(6)
34.王永其、陈吉林.做实个人账户促进医改上新台阶[J].中国卫生经济.2004.(11)
35.吴传俭.道德风险与我国社会医疗保险基金安全问题分析[J].中国卫生经济.2005.(11)
36.吴传俭.社会医疗保险道德风险博弈与防控措施研究[J].医学与哲学.2006.(7)
37.赵迪.我国社会医疗保险医方道德风险问题研究[J].商业经济.2010.(10)
38.赵曼.社会医疗保险费用约束机制与道德风险规避[J].财贸经济.2003.(2)
39.赵曼.中国劳动和社会保障发展研究报告[M].中国财政经济出版社.2002
40.赵小苏、王永其、宋余庆、王建宏.我国城镇职工基本医疗保险的道德风险及其防范[J].卫生经济研究.2001.(7)
41.郑秉文.信息不对称与医疗保险[M].经济社会体制比较.2002
42.保罗·J·费尔德斯坦.卫生保健经济学[M].北京.经济科学出版社.1998
43.约翰·伊特韦尔默里·米尔盖特、彼得·纽曼.新帕尔格雷夫经济学大辞典[M]第3卷.北京经济科学出版社,1992
44. Arrow, K. J. Uncertainty and the Welfare Economics of Medical Care, American Economic Review,53, pp.942-973
45. Pauly, Mark V. Taxation, Health Insurance and Market Failure in the Medical Economy, Journal of Economic Literature,24, June, pp.629-75
46. Evans R. G(1974), Supplier-induced demand, some empire evidence and implications pp.162-173.