医疗保险费用支付相关主体博弈分析
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摘要
在构建和谐社会时代背景下,全民获得基本医疗保险,实现病有所医,是构建和谐社会的重要任务。健全完善的医疗保险体制对于缓解人们因病而增加的经济负担以及保障和提高劳动力素质,推动经济社会发展和社会稳定能够发挥极其重要的作用。而当前基本医疗保险制度下,医疗费用支出的高速增长,导致患者经济负担加重,医疗服务机构与患者之间的矛盾已成为社会矛盾的焦点之一。要实现我国社会医疗保险平稳运行和可持续发展,解决医疗费用急速增长和医患之间矛盾已刻不容缓。对医疗保险费用支付相关主体——医疗保险机构、医疗服务机构以及参保患者行为决策探讨是解决这一问题的关键,也对于实现病有所医这一目标具有重大影响,不仅关系国民获得医疗保险水平、整个医疗保险基金的安全可持续性,而且关系社会公平。
本文运用理论分析与案例分析相结合的方法,从收益的角度对医疗保险费用支付相关主体两两博弈进行分析,探讨其博弈均衡的影响因素。搏弈分析结果：
(1)医疗保险机构与医疗服务机构之间博弈过程中, (P1,P2)是医疗服务机构和医疗保险机构博弈纳什均衡点。即医疗机构以P1(1-Z/(m[a(R+E)+E]))的概率遵守协议,而医疗保险机构则以P2(E/(m[E+a(R+E)]))的概率进行审查。而且,在均衡条件下,医院遵守协议概率P1与医疗保险机构审查成本(Z)负相关,与保险机构进行审查时的成功概率(m)、惩罚强度系数(α)正相关。保险机构审查概率P2与医疗服务不遵守协议所获得额外收益(E)正相关,而与医疗保险机构审查成功概率(m)以及惩罚强度系数(α)负相关。
(2)医疗服务机构和参保患者之间博弈分析中, (P3,P4)是二者博弈的纳什均衡点。即当定点医疗服务机构P3(1-(C2)/(m2X))提供合理诊疗,患者以P4((R2+R3)/(m2X))概率进行追查,博弈实现均衡。在均衡条件下,定点医疗服务机构合理诊疗概率P3与患者追查成本(C2)负相关,与患者追查成功获得赔偿的概率(m2)、赔偿额(X)正相关。患者追查的概率P4与医疗服务机构诊疗收益正相关,而与追查获得赔偿的概率(m2)以及赔偿额(X)负相关。
对医生和患者之间博弈进行无限次重复次博弈分析,证明二者在无限次博弈之后,医生和患者两方能够实现非零和合作博弈。当医生提供合理诊疗,患者采取信任就医行动时,即可达到均衡组合,医生和患者的整体利益实现最优。而且在博弈分析过程中,信息和信誉问题是影响博弈均衡的关键因素。在分析过程中,患者和医生重复博弈均衡受到信息因素的影响。信息因素是改变博弈地位的至关重要的因素。而良好的声誉则有助于增加彼此的信任,降低促成合作的成本,实现合作
(3)患者和医疗保险机构博弈纳什均衡为(P5,P6)。即患者以P5(C/(a(M+E)-E))的概率选择骗保,而医疗保险机构则以P6(E/(a(M+E)+E))的概率进行审查。从博弈均衡结果可以看出,二者博弈均衡结果受到患者收益M、额外收益E、医疗保险机构审查成本(C)以及惩罚系数(α)的影响。患者骗保概率P5与医疗保险机构审查成本(C)、额外收益(E)正相关,与保险机构惩罚强度系数(α)负相关。医疗保险机构审查概率P6与患者骗保所获得额外收益E正相关,而与医疗保险机构惩罚强度系数(α)负相关。
最后,针对医疗保险机构、医疗服务机构和患者行为决策影响因素,提出了改善博弈条件,促使其向合作博弈方向发展的合理建议。如：完善医疗保险支付方式；实行基本医疗服务项目及药品的统一定价制度、医药分开；建立针对医院的信用评价机制和卫生服务信息披露制度；合理的奖惩机制；扩大医疗保险覆盖面；完善费用自付制度；加大宣传力度,发挥社会监管作用；建立并充分利用医疗服务信息系统和计算机网络信息平台；加强制度建设,加大检查惩罚力度等。
In the background of building a harmonious society, It is an important task to construct the harmonious society that every one can obtain basic medical insurance. The decision of related subjects including medical institution, medical insurance institution and the patient can influence achievement of the goal which not only affects the level of social security, the safety and sustainability of health insurance funds, but also social equity.
Combining theoretical analysis and case study method, the paper analyses the game among medical institution, medical insurance institution and the patient. Through establishing and analyzing game model, it finds the equilibrium factors of the game. The game analysis results:
(1) (P1, P2) is the Nash equilibrium of medical service institutions and medical insurance institutions game. Namely medical institutions to abide by agreement in terms of Pi (1-Z(m[a(R+E)+E]))probability, while medical insurance institutions is in terms of P2(E/(m[E+a(R+E)])) probability for examination. And in equilibrium condition, P1 is negative correlation with examination cost (Z)of insurance institutions and is positive correlation with the probability of successful examining(m), punishment intensity (a). Insurance institutions examining probability P2 is positive correlation with extra income which medical service institutions don't comply with the agreement and negative correlation with successful examination probability of medical insurance institution(m) and punishment intensity(a).
(2) (P3, P4) is the Nash equilibrium of medical service institutions and insured patients game. Namely medical service institutions abide by agreement in terms of P3 (1-(C2)/(m2X)) probability, while insured patients is in terms of P4 ((R2+R3)/(m2X)probability for examination. And in equilibrium condition, P3 is negative correlation with examination cost (Z)of insured patients and is positive correlation with the probability of successful examining(m2) and compensation(X). Insured patients'examining probability P4 is positive correlation with income and is negative correlation with the probability of successful examining(m2) and compensation(X).
The analysis of doctors and patients game proved that both doctors and patients can achieve non-zero and the cooperative game after infinite games.When doctors provide reasonable treatments, the patient will trust doctors.Then they can achieve a balanced portfolio and realize the overall optimal interests. But also in the process of game analysis, the information and reputation have an important influence on the balance of the game. In the analysis, the game between patients and doctors is affected by the information. Information Factor is a crucial factor which can change the status. The reputation is helpful to increase mutual trust, promote cooperation and reduce costs in order to achieve cooperation.
(3) (P5, P6) is the Nash equilibrium of patients and medical insurance institutions game. Namely patients choose fraudulent in terms of P5 (C/(a(M+E)-E))probability, while medical insurance institutions is in terms of P6 (E/(a(M+E)+E))probability for examination. And in equilibrium condition, the nash equilibrium is affected by profits of patients(M), extra income (E),examination cost (C)of insurance institutions and punishment intensity(a).P5 is positive correlation with examination cost (C) and extra income(E).Meanwhile it is negative correlation with punishment intensity(a).P6 is positive correlation with extra income. Meanwhile it is negative correlation with punishment intensity(a).
Finally, for influencing factors of health insurance institution, medical service institution and patients, it offers some reasonable proposals to improve the game conditions and realize cooperative game. Such as:improving the health insurance payment; carrying out basic medical services the uniform medicine pricing system and medical separation institution; establishing a credit rating system for hospitals and health services information disclosure mechanisms; reasonable incentive mechanism, expanding health insurance coverage; improving the cost of pay system; increasing public awareness; establishing and making full use of health services information systems and computer network information platform; strengthen the system construction and intensify supervision and punishment and so on.
本文运用理论分析与案例分析相结合的方法,从收益的角度对医疗保险费用支付相关主体两两博弈进行分析,探讨其博弈均衡的影响因素。搏弈分析结果：
(1)医疗保险机构与医疗服务机构之间博弈过程中, (P1,P2)是医疗服务机构和医疗保险机构博弈纳什均衡点。即医疗机构以P1(1-Z/(m[a(R+E)+E]))的概率遵守协议,而医疗保险机构则以P2(E/(m[E+a(R+E)]))的概率进行审查。而且,在均衡条件下,医院遵守协议概率P1与医疗保险机构审查成本(Z)负相关,与保险机构进行审查时的成功概率(m)、惩罚强度系数(α)正相关。保险机构审查概率P2与医疗服务不遵守协议所获得额外收益(E)正相关,而与医疗保险机构审查成功概率(m)以及惩罚强度系数(α)负相关。
(2)医疗服务机构和参保患者之间博弈分析中, (P3,P4)是二者博弈的纳什均衡点。即当定点医疗服务机构P3(1-(C2)/(m2X))提供合理诊疗,患者以P4((R2+R3)/(m2X))概率进行追查,博弈实现均衡。在均衡条件下,定点医疗服务机构合理诊疗概率P3与患者追查成本(C2)负相关,与患者追查成功获得赔偿的概率(m2)、赔偿额(X)正相关。患者追查的概率P4与医疗服务机构诊疗收益正相关,而与追查获得赔偿的概率(m2)以及赔偿额(X)负相关。
对医生和患者之间博弈进行无限次重复次博弈分析,证明二者在无限次博弈之后,医生和患者两方能够实现非零和合作博弈。当医生提供合理诊疗,患者采取信任就医行动时,即可达到均衡组合,医生和患者的整体利益实现最优。而且在博弈分析过程中,信息和信誉问题是影响博弈均衡的关键因素。在分析过程中,患者和医生重复博弈均衡受到信息因素的影响。信息因素是改变博弈地位的至关重要的因素。而良好的声誉则有助于增加彼此的信任,降低促成合作的成本,实现合作
(3)患者和医疗保险机构博弈纳什均衡为(P5,P6)。即患者以P5(C/(a(M+E)-E))的概率选择骗保,而医疗保险机构则以P6(E/(a(M+E)+E))的概率进行审查。从博弈均衡结果可以看出,二者博弈均衡结果受到患者收益M、额外收益E、医疗保险机构审查成本(C)以及惩罚系数(α)的影响。患者骗保概率P5与医疗保险机构审查成本(C)、额外收益(E)正相关,与保险机构惩罚强度系数(α)负相关。医疗保险机构审查概率P6与患者骗保所获得额外收益E正相关,而与医疗保险机构惩罚强度系数(α)负相关。
最后,针对医疗保险机构、医疗服务机构和患者行为决策影响因素,提出了改善博弈条件,促使其向合作博弈方向发展的合理建议。如：完善医疗保险支付方式；实行基本医疗服务项目及药品的统一定价制度、医药分开；建立针对医院的信用评价机制和卫生服务信息披露制度；合理的奖惩机制；扩大医疗保险覆盖面；完善费用自付制度；加大宣传力度,发挥社会监管作用；建立并充分利用医疗服务信息系统和计算机网络信息平台；加强制度建设,加大检查惩罚力度等。
In the background of building a harmonious society, It is an important task to construct the harmonious society that every one can obtain basic medical insurance. The decision of related subjects including medical institution, medical insurance institution and the patient can influence achievement of the goal which not only affects the level of social security, the safety and sustainability of health insurance funds, but also social equity.
Combining theoretical analysis and case study method, the paper analyses the game among medical institution, medical insurance institution and the patient. Through establishing and analyzing game model, it finds the equilibrium factors of the game. The game analysis results:
(1) (P1, P2) is the Nash equilibrium of medical service institutions and medical insurance institutions game. Namely medical institutions to abide by agreement in terms of Pi (1-Z(m[a(R+E)+E]))probability, while medical insurance institutions is in terms of P2(E/(m[E+a(R+E)])) probability for examination. And in equilibrium condition, P1 is negative correlation with examination cost (Z)of insurance institutions and is positive correlation with the probability of successful examining(m), punishment intensity (a). Insurance institutions examining probability P2 is positive correlation with extra income which medical service institutions don't comply with the agreement and negative correlation with successful examination probability of medical insurance institution(m) and punishment intensity(a).
(2) (P3, P4) is the Nash equilibrium of medical service institutions and insured patients game. Namely medical service institutions abide by agreement in terms of P3 (1-(C2)/(m2X)) probability, while insured patients is in terms of P4 ((R2+R3)/(m2X)probability for examination. And in equilibrium condition, P3 is negative correlation with examination cost (Z)of insured patients and is positive correlation with the probability of successful examining(m2) and compensation(X). Insured patients'examining probability P4 is positive correlation with income and is negative correlation with the probability of successful examining(m2) and compensation(X).
The analysis of doctors and patients game proved that both doctors and patients can achieve non-zero and the cooperative game after infinite games.When doctors provide reasonable treatments, the patient will trust doctors.Then they can achieve a balanced portfolio and realize the overall optimal interests. But also in the process of game analysis, the information and reputation have an important influence on the balance of the game. In the analysis, the game between patients and doctors is affected by the information. Information Factor is a crucial factor which can change the status. The reputation is helpful to increase mutual trust, promote cooperation and reduce costs in order to achieve cooperation.
(3) (P5, P6) is the Nash equilibrium of patients and medical insurance institutions game. Namely patients choose fraudulent in terms of P5 (C/(a(M+E)-E))probability, while medical insurance institutions is in terms of P6 (E/(a(M+E)+E))probability for examination. And in equilibrium condition, the nash equilibrium is affected by profits of patients(M), extra income (E),examination cost (C)of insurance institutions and punishment intensity(a).P5 is positive correlation with examination cost (C) and extra income(E).Meanwhile it is negative correlation with punishment intensity(a).P6 is positive correlation with extra income. Meanwhile it is negative correlation with punishment intensity(a).
Finally, for influencing factors of health insurance institution, medical service institution and patients, it offers some reasonable proposals to improve the game conditions and realize cooperative game. Such as:improving the health insurance payment; carrying out basic medical services the uniform medicine pricing system and medical separation institution; establishing a credit rating system for hospitals and health services information disclosure mechanisms; reasonable incentive mechanism, expanding health insurance coverage; improving the cost of pay system; increasing public awareness; establishing and making full use of health services information systems and computer network information platform; strengthen the system construction and intensify supervision and punishment and so on.
引文
[1]张丹.医疗纠纷调处的法制化研究[D].吉林：吉林大学,2008.
[2]梁细列.医患纠纷现状分析及防范对策.中华现代医院管理杂志,20108(4)：50-52.
[3]陈树文.社会保障学[M].大连.大连理工大学出版社,2002：125-126.
[41李军山,江可申.医疗保险付费方式研究综述[J]中国卫生经济,2007,26(296)：17-26.
[5]Ellis R. Creaming,skimping and dumping:provider competition on the intensive and extensive margins[J]. Journal of Health Economics,1998:537-555.
[6]Ma CA. Health care payment systems:coast and quality incentives[J].Journal of Economics and Management Strategy,1994,8(3):93-112.
[7]Barros PP. Cream-skimming, incentives for efficiency and payment system [J].Journal of Health Economics,2003:419-443.
[8]Sappington D E,Lewis T R. Using subjective risk adjusting to prevent patient dumping in the health care industry[J] Journal of Economics and Management Strategy,1999,8 (3):351-382.
[9]CarrollA.B.BuehholtzA.K. Business&Soeiety:Ethiesand Stakeholder Management[M].Cineinnati,ohio:Daveshaut,1999:66.
[10]张维迎.博弈论与信息经济学[M].上海：人民出版社,2004：2.
[11]Fudenberg, Drew and Jean Tirole. Game Theory [M].MIT Press,1991:1-6.
[12]耿嘉川.不同利益主体下的中国医疗体制改革博弈[J].东岳论丛,2006,27(1)：81-84.
[13]孙华,卢亚东,王金艳.利益博弈：政府担纲社会医疗保险角色的再定位.齐齐哈尔大学学报,2008,7：70-72.
[14]李玮,黄丞,蒋馥.社会医疗保险中欺诈问题的博弈分析[J].上海交通大学学报,2004,38(3)：471-473.
[15]毛瑛,范文斌,王枫叶.我国城镇职工基本医疗保险道德风险博弈分析[J].中国医学伦理学,2006,19(4)：79-81.
[16]刘纬宇.保险代理机制设计与医疗保险欺诈博弈分析[D].武汉：华中科技大学,2007.
[17]李玮,黄丞,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[J].预测,2003,22(1)：46-49.
[18]边文霞.医疗保险欺诈信号传递博弈分析[J].首都经济贸易大学学报,2004,5：69-72.
[19]包文彬,顾海彬.医疗保险体系中的博弈均衡分析[J].中外科技信息产业纵深,2001,12：24-26.
[20]周绿林.我国医疗保险费用控制研究[D].江苏：江苏大学,2008.
[21]刘鹏涛,芦巧玲,魏佳.基于医、保、患博弈关系的医疗保险费用控制策略研究[J].西部财会,2010：56-58.
[22]石宏伟,吕序榕,王小娇.镇江市社会医疗保险中企业逃费问题博弈分析及对策[J].中国卫生经济,2009,28(6)：59-61.
[23]张翼飞,龚勋.医疗保险中欺诈问题的博弈分析[J].现代医院管理,2009,4：12-14.
[24]陈新中,张毅.博弈下的利益均衡：镇江市社会医疗保险结算办法的演变[J].卫生经济研究,2001，3：17-20.
[25]王鉴岗.医疗费用世界难题最优解的博弈论分析[J].社会保障研究,2001.
[26]李军山,江可申,陈和利.社会医疗保险付费方式的博弈分析.系统工程理论与实践,2008,11：36-42.
[27]钟胜,罗琳.保险公司与医院合作的博弈分析[J].运筹与管理,2004,3(13)：90-94.
[28]张帆,姚俭.基于委托人-代理人关系的患者就医行为研究[J].上海理工大学学报(社会科学版),2005,4(27)：63-65.
[29]卡尔.N.博尔奇.保险经济学[M].商务印书馆,1999.
[30]曾国安.论信息不对称产生的原因与经济后果[J].经济学动态,1999,(11).
[31]Fuchs VR. The Supply of Surgeon sand the Demand for OP erations [J].The Journal of Human Resouree,1978,13 (1):35-36.
[32]李伟.城镇医保改革三方博弈关系及现状分析[D].吉林：吉林大学,2007.
[33]洪光初,周传章.医疗保险：新型农村合作医疗的发展方向[J].江苏卫生保健,2003.5.
[34]石宏伟,吕序榕,王小娇.镇江市社会医疗保险中企业逃费为题博弈分析及对策[J].中国卫生经济,2009,28(6)：59-61.
[35]蔡玉娟.健康保险中道德风险问题的博弈分析及对策研究[D].重庆：重庆大学,2006.
[2]梁细列.医患纠纷现状分析及防范对策.中华现代医院管理杂志,20108(4)：50-52.
[3]陈树文.社会保障学[M].大连.大连理工大学出版社,2002：125-126.
[41李军山,江可申.医疗保险付费方式研究综述[J]中国卫生经济,2007,26(296)：17-26.
[5]Ellis R. Creaming,skimping and dumping:provider competition on the intensive and extensive margins[J]. Journal of Health Economics,1998:537-555.
[6]Ma CA. Health care payment systems:coast and quality incentives[J].Journal of Economics and Management Strategy,1994,8(3):93-112.
[7]Barros PP. Cream-skimming, incentives for efficiency and payment system [J].Journal of Health Economics,2003:419-443.
[8]Sappington D E,Lewis T R. Using subjective risk adjusting to prevent patient dumping in the health care industry[J] Journal of Economics and Management Strategy,1999,8 (3):351-382.
[9]CarrollA.B.BuehholtzA.K. Business&Soeiety:Ethiesand Stakeholder Management[M].Cineinnati,ohio:Daveshaut,1999:66.
[10]张维迎.博弈论与信息经济学[M].上海：人民出版社,2004：2.
[11]Fudenberg, Drew and Jean Tirole. Game Theory [M].MIT Press,1991:1-6.
[12]耿嘉川.不同利益主体下的中国医疗体制改革博弈[J].东岳论丛,2006,27(1)：81-84.
[13]孙华,卢亚东,王金艳.利益博弈：政府担纲社会医疗保险角色的再定位.齐齐哈尔大学学报,2008,7：70-72.
[14]李玮,黄丞,蒋馥.社会医疗保险中欺诈问题的博弈分析[J].上海交通大学学报,2004,38(3)：471-473.
[15]毛瑛,范文斌,王枫叶.我国城镇职工基本医疗保险道德风险博弈分析[J].中国医学伦理学,2006,19(4)：79-81.
[16]刘纬宇.保险代理机制设计与医疗保险欺诈博弈分析[D].武汉：华中科技大学,2007.
[17]李玮,黄丞,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[J].预测,2003,22(1)：46-49.
[18]边文霞.医疗保险欺诈信号传递博弈分析[J].首都经济贸易大学学报,2004,5：69-72.
[19]包文彬,顾海彬.医疗保险体系中的博弈均衡分析[J].中外科技信息产业纵深,2001,12：24-26.
[20]周绿林.我国医疗保险费用控制研究[D].江苏：江苏大学,2008.
[21]刘鹏涛,芦巧玲,魏佳.基于医、保、患博弈关系的医疗保险费用控制策略研究[J].西部财会,2010：56-58.
[22]石宏伟,吕序榕,王小娇.镇江市社会医疗保险中企业逃费问题博弈分析及对策[J].中国卫生经济,2009,28(6)：59-61.
[23]张翼飞,龚勋.医疗保险中欺诈问题的博弈分析[J].现代医院管理,2009,4：12-14.
[24]陈新中,张毅.博弈下的利益均衡：镇江市社会医疗保险结算办法的演变[J].卫生经济研究,2001，3：17-20.
[25]王鉴岗.医疗费用世界难题最优解的博弈论分析[J].社会保障研究,2001.
[26]李军山,江可申,陈和利.社会医疗保险付费方式的博弈分析.系统工程理论与实践,2008,11：36-42.
[27]钟胜,罗琳.保险公司与医院合作的博弈分析[J].运筹与管理,2004,3(13)：90-94.
[28]张帆,姚俭.基于委托人-代理人关系的患者就医行为研究[J].上海理工大学学报(社会科学版),2005,4(27)：63-65.
[29]卡尔.N.博尔奇.保险经济学[M].商务印书馆,1999.
[30]曾国安.论信息不对称产生的原因与经济后果[J].经济学动态,1999,(11).
[31]Fuchs VR. The Supply of Surgeon sand the Demand for OP erations [J].The Journal of Human Resouree,1978,13 (1):35-36.
[32]李伟.城镇医保改革三方博弈关系及现状分析[D].吉林：吉林大学,2007.
[33]洪光初,周传章.医疗保险：新型农村合作医疗的发展方向[J].江苏卫生保健,2003.5.
[34]石宏伟,吕序榕,王小娇.镇江市社会医疗保险中企业逃费为题博弈分析及对策[J].中国卫生经济,2009,28(6)：59-61.
[35]蔡玉娟.健康保险中道德风险问题的博弈分析及对策研究[D].重庆：重庆大学,2006.