我国社会医医保险险判机制研究
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摘要
研究目的与意义
试图通过对社会医疗保险领域相关主体的博弈方式深入分析,进一步明确社会医疗保险谈判机制的实质内涵的基础上,形成一套有关社会医疗保险谈判机制的基本框架,并探索符合国情的社会医疗保险谈判机制的实施路径。立足社会医疗保险谈判机制的创立,对于更充分发挥医疗保险基金的使用效率,协调医疗相关利益方形成合力,推动中国医药卫生体制改革,促进医疗服务市场健康有序发展,具有重要的理论与现实意义。
研究方法
采用文献计量法和内容分析法对收集到的有关社会医疗保险谈判的文献进行定量和半定量分析,系统收集社会医疗保险谈判机制构建的核心要素。采用博弈论分析不完全信息状态下的医保、医疗机构委托代理行为,完成医保谈判理论模型构建。采用问卷调查、知情人深度访谈了解医疗保险机构与医疗机构谈判议价现状、存在的问题及影响因素。数据分析方法:描述性分析,计量资料的均值、标准差计算;高级SWOT分析对医保谈判机制构建与发展的内外环境做了准确的分析并明确了发展战略;采用时间序列分析实证研究追踪了医院支付方式改革以后的医疗行为;数据分析主要采用Eviews5、Super Decisions、SPSS 12.0等软件处理。
研究结果
1.文献计量分析:检索到近5年42篇标准文献,经过计量分析及内容分析,综合文献信息对6个医保谈判机制核心要素做了初步界定,包括:谈判模式、谈判主体、谈判内容、谈判程序、谈判规则、相关支撑机制。
2.相关理论基础分析:筛选出谈判理论、公共管理理论、帕累托最优以及契约论等与医疗保险谈判机制相关的理论,并探讨各理论对医保谈判机制的贡献及应用。首先,谈判理论:通过谈判以期进行合作的过程是一种合作博弈,谈判过程分为三个阶段:确定风险值,预测合作剩余,分配合作剩余。其次,公共管理学价值:谈判利用公平的程序让多方利益充分表达,确保决策正当性与合法性。第三,帕累托最优:通过责权利的重新规范完全可以实现帕累托改进,达到帕累托最优。第四,医疗保险协议也可以称之为医疗保险契约,协议管理是医保谈判的初级阶段形式,可以明确主体、客体和内容等法律关系。
3.实践现状分析:罗列了我国谈判双方的基本情况,并与国际对比,表明我国医保机构的谈判力量较为薄弱,控费手段较为落后。地位不平等,导致在协议管理(医保谈判初级形式)的协议签订、履行中出现不和谐因素,增加了交易成本,降低了医保基金使用效率。并结合国际研究,主要探讨了市场集中度对医保谈判的影响,并以湖北省作为对象做了实证研究,湖北省医疗服务产业市场集中度CR_4达67.82%,表明市场集中度很高,建议对医院采取管办分开、对医保机构设立第三方监管机制可以提高医保谈判的效率。本部分最后还结合现状做了医保谈判的SWOT分析,发现我国医保谈判机制的构建与发展处于WO状态,即内部环境亟待改善、外部环境较好,需采取利用机会、克服劣势的策略。
4.博弈模型构建:通过博弈论的一般分析并结合医保的特点构建医疗保险谈判的理论模型。首先,支付方式是医保与医院谈判的核心,在某种支付方式或组合支付方式下,如何达到医保、医院利益均衡并控制好医疗费用就是医保谈判要解决的首要问题。建议改目前动态博弈为静态博弈,可以实现医保与医院收益同时最大化。其次,根据国际上的谈判模式分类,医保谈判模型可分为2类:个体谈判模式模型和集体谈判模式模型。个体谈判模式模型:医院如果认清长期恶性竞争都选择不控费的结果,势必都争取不到更多的医疗收入;因此对于医院合作是最佳的选择,这种合作博弈的结果是正和博弈。集体谈判模式模型:实为双边垄断模型和道德风险模型。双边垄断模型证明形成医-保联盟合作博弈是一种理性选择。道德风险模型说明,医保分会道德风险会造成医院的损失,可通过医院的集体威胁行为来防范协会的道德风险,降低各医院的权益损失。最后结合新医改公立医院改革导向,以非营利性医院的医保谈判为主体展开探索,进行非营利性医院医保交易设计,通过模型分析,在总额预算条件下,政策制定者要加强限制非营利性医院仅提供高质量医疗服务而不注重医疗服务数量的情况。针对医疗服务数量激励不足的问题,建议可采用“按服务单元”医保支付方式进行激励,加上总额预算,形成组合医保支付方式会使医保交易更加合理。
5.案例研究:结合根据前述理论及样本地区调查,选出相关典型案例深入剖析,诠释医保谈判机制构建及开展情况。案例一,镇江是国务院确定的首批医疗保险制度改革试点城市,在基金预决算指标和结算过程、医疗服务质量控制、团购医药服务中应用谈判机制总结出好的经验。案例二,将已经出台医保谈判机制文本的镇江市和成都市做了细节比较,为向全国推广提供依据。案例三,医保谈判是动态的,研究新医保协议的变化对医院行为的影响对下一轮谈判具有政策意义,本部分研究采用时间序列法(Time Series),以一个县医院医保支付方式变化带来医院行为变化为例来说明,研究发现:医保支付方式从按项目付费改为按床日付费后,医疗费用没有明显增加;从医保病人各明细项目医疗费用构成的时间序列的变化来看,西药费下降,表明出按床日付费的控费效果从降低西药费显现;未发现支付方式改革对病人的住院时间的影响;医保谈判要及时关注支付方式等重要情况带来的影响以便快速动态反应。案例四,某大型医院(明星医院)不启动医保谈判的原因从现实状况及逆向选择理论分析,可以合理解释为,如果医保机构对其是否参加医保无强制性,大型医院就会放弃参保,并对不同的对象、不同的服务项目采取价格歧视最终达到利润最大化。
6.实务规则:目前医疗保险制度改革面临的困境迫切需要将医保谈判从理论研究推向具体实践,需要一套具有可操作性的医保谈判实务规则。本部分理论研究和实证分析相结合,系统提出操作性强的我国医保谈判实务规则。确立了具体目标:优化配置医疗服务资源、有效控制医疗服务和药品费用;基本原则:参保人利益最大化原则、公平优先兼顾效率、医患保多方互利共赢。展示了医保谈判的初步框架,从准备阶段、正式谈判阶段、协议履行阶段、监管制度等方面提出了新要求。综合以上论述,形成了《构建医疗保险谈判机制准则》概要。最后针对准则进行了医保谈判机制定性论证和定量论证,经过知情人访谈,明晰了准则中涉及的谈判行为关系、影响谈判的因素、谈判的问题、纠纷以及改善方式、谈判过程中的策略等;经过准则的认可程度专家论证,总体认可程度较高,均达到80%以上,究其不认可的原因也做了分析并提出相应对策。
7.医疗保险谈判机制构建对策:借鉴国际经验,结合我国医保改革的阶段及我国国情特点,从系统、组织、个体三个层面提出相应对策和建议。系统层面,做好顶层设计,“准确定位,锁定目标”、经由“科学设计”、“战略控制”,确保目标“执行到位”;组织层面,医保机构要更新观念、引入竞争,而医疗机构也要重新定位,并且力量要整合,谈判意识和动力要提高;个体层面,控制医生的道德风险,加强参保者在医保谈判中的参与度,进行参保者教育是主要措施。
研究结论
1.我国谈判双方的基本情况对比,表明我国医保机构的谈判力量较为薄弱,控费手段较为落后,医疗服务市场集中度很高,公立医院垄断性较强。
2.经过医保谈判的SWOT分析,得出我国医保谈判机制的构建与发展处于WO环境,即内部环境亟待改善、外部环境较好,需采取WO对策,利用机会、克服劣势。
3.如果医保机构与医疗机构之间的动态博弈改为静态博弈,在一定条件下可以实现医保与医疗机构收益同时最大化。
4.对非营利性医院而言,建议可采用“按服务单元”加上总额预算形成组合医保支付方式会使医保交易更加合理。
5.不论是个体谈判还是集体谈判,需要将非合作博弈转化为合作博弈,形成联盟,最终可以实现帕累托最优。
6.系统提出操作性强的我国医保谈判实务规则,形成《构建医疗保险谈判机制准则》概要,并经过定性定量论证,概要获得广泛认同,可以尝试实施。
研究创新与价值
理论创新,社会医疗保险谈判机制的理论研究和实践工作刚起步,迫切需要研究。本研究在明确医保谈判机制的实质内涵基础上,形成医保谈判机制的基本理论框架,并制定出符合我国国情的实务规则。
方法创新:采用市场集中度的方法分析医保谈判双方的定位,采用高级SWOT分析对明确了医保谈判现状及发展战略,采用时间序列分析法实证研究追踪了医院支付方式改革以后的医疗行为,医保谈判双方博弈结合医院行为综合建模,这些研究方法克服了传统医疗保险研究专注某一方面方法研究的局限性,模拟过程更贴近实际过程,研究结果更稳定,因此结论更为可信。
政策价值:立足于中国现实,参照国际医保谈判机制发展的一般规律,建立一套科学的医保谈判机制框架,并制定相应实务规则,对全国医保谈判机制顺利实施具有重要的实用价值;获得的丰富定量数据,从多方面对目前医疗保险谈判的现实情况进行分析,为我国有关决策部门制定医疗保险谈判机制方案提供政策依据。
Objective
Through profound analysis of principal subjects in social health insurance field on the main game mode, the author tried to further clarify the essence mean of negotiation mechanisms on social health insurance. Subsequently, the article formated the basic framework of negotiation mechanism on social health insurance, and looked for a implementation pathway with the national social health insurance negotiation. With construction of negotiation mechanism, it would improve use efficiency of funds about health insurance and coordinate the relation of health care stakeholders. On the whole it had important theoretical and practical significance in all fields about the development of China’s health reform and the medical services market.
Methods
Through quantitative and semi-quantitative analysis for the literature of social health insurance negotiations by bibliometric methods and content analysis, the author systematically collected the core elements of the social health insurance negotiations mechanism. With incomplete information principal-agent analysis between hospitals and health insurers, negotiation theory model building was complete. Some questionnaire surveys and in-depth interviews for knowledgeable informants were carried out to understand the current situation, problems, influential factors of negotiations and bargaining with both sides. Data analysis: Descriptive analysis including measurement data of the mean, standard deviation. By advanced SWOT analysis accurate analysis and clear development strategy was made for the construction and development of health care bargaining internal and external environment.Using time series analysis method to track the empirical research reform of the hospital after payment of medical acts. Data analysis were mainly by softwares such Eviews5, Super Decisions, SPSS 12.0 and so on.
Results
1. Bibliometric analysis of health insurance negotiation mechanisms: The thesis retrieved 42 standard literatures of health insurance negotiation mechanisms in the last 5 years, through the methods of quantitative analysis and content analysis. The six core elements of negotiation mechanisms were defined preliminarily by comprehensive health insurance document information, including the mode, the main bodies, content, procedures of negotiations and related supporting mechanisms.
2. Related theory: Some theories were selected to described such as negotiation theory, public administration theory, Pareto optimality theory and contract theory on health insurance. Then the contribution and its application was analyzed with the above theories for the theory of the negotiation mechanism on the health insurance. Firstly, negotiation Theory: changing a negotiated process of cooperation to a cooperative game. Second, the value of public administration theory: negotiating used fair procedures to express fully with multiple interests in order to ensure the legitimacy and legality of decisions. Thirdly, Pareto optimality theory: the re-specification to duty-power-benefit could achieve Pareto improvement to Pareto optimal. Fourthly, the health insurance agreement could also be called the health insurance contract. The agreement management was the initial stage of health insurance negotiations. Then we could know legal relations with the subject, object and content.
3. Practice Analysis: Comparing with international level, a list of the basic situation of the negotiating parties showed that our health insurer had relatively weak bargaining power, controlling costs means more backward. Inequality resulted some discord factors in the agreement management (the primary form of health insurance negotiations) for the phases of signing agreement and fulfilling agreement that increased transaction costs and reduce the health insurance fund efficiency. Combined with international research, the thesis focused on the market concentration impact on the health care negotiations, and put Hubei empirical research as an object to confirm. The medical services industry in Hubei Province reached 67.82 percent of market concentration, indicating a high degree of market concentration.The author suggested that public hospitals should be separated regulating and running of health care organizations and the government should set up third-party monitoring mechanism to improve the efficiency of health care negotiations. Finally, in this part of the combination of health insurance status of the negotiations SWOT analysis was made. The atuthor found that the reality of health care bargaining was WO construction and development in the environment. It was urgently needed to improve the internal environment, external environment by using the opportunity and overcoming the disadvantage.
4. Game model: Based on the general analysis of game theory combined with the characteristics of health insurance negotiations, a theoretical model was successfully built. First of all, health care payment was the core of the negotiations with the hospital. Under certain single payment method or combined method in a payment, it was the primary problem in health care negotiations to solve that how to achieve a win-win status between health insurance and hospitals and control the balance of interests in health care costs. Proposal to change the current dynamic game for the static game, could be achieved while maximizing health insurance and hospital benefits. Secondly, the negotiations in accordance with international classification, health care bargaining model could be divided into two categories: individual negotiation model and collective bargaining negotiation model. Individual negotiation model: if they recognized the hospital vicious competition for the long-term results and chose not to control cost, they were bound to earn not any more income.Thus for the hospitals their cooperation was the best option and it was a result of cooperative game non-zero sum game. Collective bargaining model model: bilateral monopoly model and moral hazard model indeed. bilateral monopoly model showed that the rational choice was combined them together into cooperation organization. Because hospital association of moral hazard could cause the loss of the hospital, It may be prevent moral hazard and reduce loss of interest in various hospitals with threatening by the collective behavior of the hospital association. Finally, combined with new health reform-oriented, non-profit health care negotiations would be the main model for hospitals to start exploring the design of non-profit hospitals health insurance transactions. Through modeling, under the total budget conditions, the policy makers should prevent non-profit hospitals to concentrate on providing more high-quality medical services in health care by ignoring the number of cases. To stimulate insufficient incentives for the number of medical problems, the advice may be "by service unit" . Health care payment would form a combination of a more rational health care transactions.
5. Case study: According to the aformentioned theory and surveies about sample areas, typical cases were selected and analyzed in-depth to interpretate construction and negotiation mechanism development. CaseⅠ, Zhenjiang was the first pilot city for the medical insurance system reform assigned by State Council. Some experiences were well summed up in the index fund budget and final accounts and settlement processes , quality controling of medical services, and buying medical services for a great quantity. CaseⅡdescribed negotiation mechanism the details by comparing the Zhenjiang’s policy with Chengdu’s. CaseⅢwas a dynamic health care negotiations. The new agreement would cause hospital behavior change on the next round of negotiations with the policy implications. In this part of the study, time series was used to analyze changes in behavior as an example to illustrate the hospital behavior for payment changes in a county hospital. The study found: Though health care payment paid by the project from the bed at a charge to press, there was no significant increase in medical costs and others except for medicine costs down. Negotiate payment and other important and timely attention should be given to changing circumstances in order to fast dynamic response. CaseⅣ, In certain large hospital (star hospital) health insurance did not start because the negotiations and the adverse selection from the reality of theoretical analysis.The author suggested that if health care organizations to participate in medicare as to whether non-mandatory, large hospitals would give the insured people and the different objects, different services to adopt price discrimination to maximize profits.
6. Practice rules:For the current medical insurance system reform dilemma and the urgent need to push health care negotiations from the theory to health care negotiating practice a set of workable rules should be constructed. Through theoretical and empirical analysis, the system made workable rules of practice of health care negotiations. Established specific objectives: optimal allocation of medical resources, medical services and medicines to effectively control costs. Basic principles: the principle of maximizing the interests of the insured person, a fair balance between efficiency priority, multi-win-win physician-patient-insurer. The thesis showed the initial framework for health insurance negotiations, from the preparation stage, formal phase of negotiations, an agreement to perform stage, regulatory and other aspects of the new requirements. Based on the above discussion, a guideline named " Summary on mechanism for building guidelines for health insurance negotiations"was formatted. Finally, guidelines for negotiating mechanisms did recognition of the extent of health care experts. A higher degree percent of overall recognition were 80, and the reasons for its non-recognition are also analyzed and put corresponding countermeasures.
7.Countermeasures to construction of health insurance negotiations: Learning from international experience, under the background of health reform in our country and our national conditions, corresponding countermeasures and suggestions was put forward from three levels among the system, organization and individual level. On the system level, a good top-level design includes "precise positioning, targeted", "scientific design ","strategic control","the implementation of place". On the organizational level, health care institutions to new ideas, the introduction of competition, and medical institutions To re-positioning, and the power to integrate, the negotiations to increase awareness and motivation.On the individual level, the moral hazard of medical practitioners must be controlled and enrollment rate of insured persons should be enhanced in the negotiations besides that the insured person should accept the main measure of education.
Conclusions
1. Based on situation analysis of the negotiating parties, it showed that the bargaining power of health insurer was weaker and means of controlling costs was lagging behind. As a result, a high degree of market concentration in health care field caused public hospitals showing monopoly-oriented.
2. After negotiations SWOT analysis, the construction of the mechanism of health care negotiations lay in a WO environment. That’s to say, it was urgent to improve the internal environment. WO measures must to be taken by using better opportunities and overcoming disadvantages.
3. If we changed the static game of the health insurer and medical institutions into dynamic game, these two parties could achieve maximizing revenue at the same time under certain conditions.
4. For non-profit hospitals as the main, the combination payment method may be reasonable including "by service unit" and "globe budget ".
5. Whether individual or collective bargaining negotiation, it needed to change non-cooperative game into cooperative game in order to ultimately achieve Pareto optimality.
6. Negotiating workable rules of practice was made systematically. Guidelines summary for building health insurance bargaining was formed initially. And after qualitative and quantitative arguments, the outline was widely recognized and could try to implement.
Innovations and merits
Theoretical innovation: Social health insurance bargaining theory research and practice had just started so that it urgently need to study. Based on the negotiation mechanism in the clear substance, the study formed the basic theoretical framework of negotiations mechanism and developed rules of practice in line with our national conditions.
Innovation of methods: market concentration method was used to position the negotiating parties. Advanced SWOT analysis was identified for the development of health insurance status of the negotiations and strategies. As an empirical study, time series analysis method was adoped to track the hospital behavior after payment reform medical practices. Health insurance negotiation game of two hospitals combining behavioral synthesis modeling was constructed. These methods overcome the traditional focused on one aspect of health insurance by the limitations of methods. They could simulate the process closer to the actual process and the results were more stable. Therefore we could get more credible conclusions.
Policy value: Based on China's realities, with reference to the general rules of negotiation mechanisms of the development of international health insurance, the study established a scientific framework for health care negotiation mechanism and developed appropriate rules of practice. These above had important practical value for the smooth implementation of the national health insurance negotiation mechanism. The study was consisted with rich quantitative data of health insurance negotiations. The current reality was analyzed from various views for formulation of policy-making departments to provide health insurance program policy basis for negotiation mechanism.
试图通过对社会医疗保险领域相关主体的博弈方式深入分析,进一步明确社会医疗保险谈判机制的实质内涵的基础上,形成一套有关社会医疗保险谈判机制的基本框架,并探索符合国情的社会医疗保险谈判机制的实施路径。立足社会医疗保险谈判机制的创立,对于更充分发挥医疗保险基金的使用效率,协调医疗相关利益方形成合力,推动中国医药卫生体制改革,促进医疗服务市场健康有序发展,具有重要的理论与现实意义。
研究方法
采用文献计量法和内容分析法对收集到的有关社会医疗保险谈判的文献进行定量和半定量分析,系统收集社会医疗保险谈判机制构建的核心要素。采用博弈论分析不完全信息状态下的医保、医疗机构委托代理行为,完成医保谈判理论模型构建。采用问卷调查、知情人深度访谈了解医疗保险机构与医疗机构谈判议价现状、存在的问题及影响因素。数据分析方法:描述性分析,计量资料的均值、标准差计算;高级SWOT分析对医保谈判机制构建与发展的内外环境做了准确的分析并明确了发展战略;采用时间序列分析实证研究追踪了医院支付方式改革以后的医疗行为;数据分析主要采用Eviews5、Super Decisions、SPSS 12.0等软件处理。
研究结果
1.文献计量分析:检索到近5年42篇标准文献,经过计量分析及内容分析,综合文献信息对6个医保谈判机制核心要素做了初步界定,包括:谈判模式、谈判主体、谈判内容、谈判程序、谈判规则、相关支撑机制。
2.相关理论基础分析:筛选出谈判理论、公共管理理论、帕累托最优以及契约论等与医疗保险谈判机制相关的理论,并探讨各理论对医保谈判机制的贡献及应用。首先,谈判理论:通过谈判以期进行合作的过程是一种合作博弈,谈判过程分为三个阶段:确定风险值,预测合作剩余,分配合作剩余。其次,公共管理学价值:谈判利用公平的程序让多方利益充分表达,确保决策正当性与合法性。第三,帕累托最优:通过责权利的重新规范完全可以实现帕累托改进,达到帕累托最优。第四,医疗保险协议也可以称之为医疗保险契约,协议管理是医保谈判的初级阶段形式,可以明确主体、客体和内容等法律关系。
3.实践现状分析:罗列了我国谈判双方的基本情况,并与国际对比,表明我国医保机构的谈判力量较为薄弱,控费手段较为落后。地位不平等,导致在协议管理(医保谈判初级形式)的协议签订、履行中出现不和谐因素,增加了交易成本,降低了医保基金使用效率。并结合国际研究,主要探讨了市场集中度对医保谈判的影响,并以湖北省作为对象做了实证研究,湖北省医疗服务产业市场集中度CR_4达67.82%,表明市场集中度很高,建议对医院采取管办分开、对医保机构设立第三方监管机制可以提高医保谈判的效率。本部分最后还结合现状做了医保谈判的SWOT分析,发现我国医保谈判机制的构建与发展处于WO状态,即内部环境亟待改善、外部环境较好,需采取利用机会、克服劣势的策略。
4.博弈模型构建:通过博弈论的一般分析并结合医保的特点构建医疗保险谈判的理论模型。首先,支付方式是医保与医院谈判的核心,在某种支付方式或组合支付方式下,如何达到医保、医院利益均衡并控制好医疗费用就是医保谈判要解决的首要问题。建议改目前动态博弈为静态博弈,可以实现医保与医院收益同时最大化。其次,根据国际上的谈判模式分类,医保谈判模型可分为2类:个体谈判模式模型和集体谈判模式模型。个体谈判模式模型:医院如果认清长期恶性竞争都选择不控费的结果,势必都争取不到更多的医疗收入;因此对于医院合作是最佳的选择,这种合作博弈的结果是正和博弈。集体谈判模式模型:实为双边垄断模型和道德风险模型。双边垄断模型证明形成医-保联盟合作博弈是一种理性选择。道德风险模型说明,医保分会道德风险会造成医院的损失,可通过医院的集体威胁行为来防范协会的道德风险,降低各医院的权益损失。最后结合新医改公立医院改革导向,以非营利性医院的医保谈判为主体展开探索,进行非营利性医院医保交易设计,通过模型分析,在总额预算条件下,政策制定者要加强限制非营利性医院仅提供高质量医疗服务而不注重医疗服务数量的情况。针对医疗服务数量激励不足的问题,建议可采用“按服务单元”医保支付方式进行激励,加上总额预算,形成组合医保支付方式会使医保交易更加合理。
5.案例研究:结合根据前述理论及样本地区调查,选出相关典型案例深入剖析,诠释医保谈判机制构建及开展情况。案例一,镇江是国务院确定的首批医疗保险制度改革试点城市,在基金预决算指标和结算过程、医疗服务质量控制、团购医药服务中应用谈判机制总结出好的经验。案例二,将已经出台医保谈判机制文本的镇江市和成都市做了细节比较,为向全国推广提供依据。案例三,医保谈判是动态的,研究新医保协议的变化对医院行为的影响对下一轮谈判具有政策意义,本部分研究采用时间序列法(Time Series),以一个县医院医保支付方式变化带来医院行为变化为例来说明,研究发现:医保支付方式从按项目付费改为按床日付费后,医疗费用没有明显增加;从医保病人各明细项目医疗费用构成的时间序列的变化来看,西药费下降,表明出按床日付费的控费效果从降低西药费显现;未发现支付方式改革对病人的住院时间的影响;医保谈判要及时关注支付方式等重要情况带来的影响以便快速动态反应。案例四,某大型医院(明星医院)不启动医保谈判的原因从现实状况及逆向选择理论分析,可以合理解释为,如果医保机构对其是否参加医保无强制性,大型医院就会放弃参保,并对不同的对象、不同的服务项目采取价格歧视最终达到利润最大化。
6.实务规则:目前医疗保险制度改革面临的困境迫切需要将医保谈判从理论研究推向具体实践,需要一套具有可操作性的医保谈判实务规则。本部分理论研究和实证分析相结合,系统提出操作性强的我国医保谈判实务规则。确立了具体目标:优化配置医疗服务资源、有效控制医疗服务和药品费用;基本原则:参保人利益最大化原则、公平优先兼顾效率、医患保多方互利共赢。展示了医保谈判的初步框架,从准备阶段、正式谈判阶段、协议履行阶段、监管制度等方面提出了新要求。综合以上论述,形成了《构建医疗保险谈判机制准则》概要。最后针对准则进行了医保谈判机制定性论证和定量论证,经过知情人访谈,明晰了准则中涉及的谈判行为关系、影响谈判的因素、谈判的问题、纠纷以及改善方式、谈判过程中的策略等;经过准则的认可程度专家论证,总体认可程度较高,均达到80%以上,究其不认可的原因也做了分析并提出相应对策。
7.医疗保险谈判机制构建对策:借鉴国际经验,结合我国医保改革的阶段及我国国情特点,从系统、组织、个体三个层面提出相应对策和建议。系统层面,做好顶层设计,“准确定位,锁定目标”、经由“科学设计”、“战略控制”,确保目标“执行到位”;组织层面,医保机构要更新观念、引入竞争,而医疗机构也要重新定位,并且力量要整合,谈判意识和动力要提高;个体层面,控制医生的道德风险,加强参保者在医保谈判中的参与度,进行参保者教育是主要措施。
研究结论
1.我国谈判双方的基本情况对比,表明我国医保机构的谈判力量较为薄弱,控费手段较为落后,医疗服务市场集中度很高,公立医院垄断性较强。
2.经过医保谈判的SWOT分析,得出我国医保谈判机制的构建与发展处于WO环境,即内部环境亟待改善、外部环境较好,需采取WO对策,利用机会、克服劣势。
3.如果医保机构与医疗机构之间的动态博弈改为静态博弈,在一定条件下可以实现医保与医疗机构收益同时最大化。
4.对非营利性医院而言,建议可采用“按服务单元”加上总额预算形成组合医保支付方式会使医保交易更加合理。
5.不论是个体谈判还是集体谈判,需要将非合作博弈转化为合作博弈,形成联盟,最终可以实现帕累托最优。
6.系统提出操作性强的我国医保谈判实务规则,形成《构建医疗保险谈判机制准则》概要,并经过定性定量论证,概要获得广泛认同,可以尝试实施。
研究创新与价值
理论创新,社会医疗保险谈判机制的理论研究和实践工作刚起步,迫切需要研究。本研究在明确医保谈判机制的实质内涵基础上,形成医保谈判机制的基本理论框架,并制定出符合我国国情的实务规则。
方法创新:采用市场集中度的方法分析医保谈判双方的定位,采用高级SWOT分析对明确了医保谈判现状及发展战略,采用时间序列分析法实证研究追踪了医院支付方式改革以后的医疗行为,医保谈判双方博弈结合医院行为综合建模,这些研究方法克服了传统医疗保险研究专注某一方面方法研究的局限性,模拟过程更贴近实际过程,研究结果更稳定,因此结论更为可信。
政策价值:立足于中国现实,参照国际医保谈判机制发展的一般规律,建立一套科学的医保谈判机制框架,并制定相应实务规则,对全国医保谈判机制顺利实施具有重要的实用价值;获得的丰富定量数据,从多方面对目前医疗保险谈判的现实情况进行分析,为我国有关决策部门制定医疗保险谈判机制方案提供政策依据。
Objective
Through profound analysis of principal subjects in social health insurance field on the main game mode, the author tried to further clarify the essence mean of negotiation mechanisms on social health insurance. Subsequently, the article formated the basic framework of negotiation mechanism on social health insurance, and looked for a implementation pathway with the national social health insurance negotiation. With construction of negotiation mechanism, it would improve use efficiency of funds about health insurance and coordinate the relation of health care stakeholders. On the whole it had important theoretical and practical significance in all fields about the development of China’s health reform and the medical services market.
Methods
Through quantitative and semi-quantitative analysis for the literature of social health insurance negotiations by bibliometric methods and content analysis, the author systematically collected the core elements of the social health insurance negotiations mechanism. With incomplete information principal-agent analysis between hospitals and health insurers, negotiation theory model building was complete. Some questionnaire surveys and in-depth interviews for knowledgeable informants were carried out to understand the current situation, problems, influential factors of negotiations and bargaining with both sides. Data analysis: Descriptive analysis including measurement data of the mean, standard deviation. By advanced SWOT analysis accurate analysis and clear development strategy was made for the construction and development of health care bargaining internal and external environment.Using time series analysis method to track the empirical research reform of the hospital after payment of medical acts. Data analysis were mainly by softwares such Eviews5, Super Decisions, SPSS 12.0 and so on.
Results
1. Bibliometric analysis of health insurance negotiation mechanisms: The thesis retrieved 42 standard literatures of health insurance negotiation mechanisms in the last 5 years, through the methods of quantitative analysis and content analysis. The six core elements of negotiation mechanisms were defined preliminarily by comprehensive health insurance document information, including the mode, the main bodies, content, procedures of negotiations and related supporting mechanisms.
2. Related theory: Some theories were selected to described such as negotiation theory, public administration theory, Pareto optimality theory and contract theory on health insurance. Then the contribution and its application was analyzed with the above theories for the theory of the negotiation mechanism on the health insurance. Firstly, negotiation Theory: changing a negotiated process of cooperation to a cooperative game. Second, the value of public administration theory: negotiating used fair procedures to express fully with multiple interests in order to ensure the legitimacy and legality of decisions. Thirdly, Pareto optimality theory: the re-specification to duty-power-benefit could achieve Pareto improvement to Pareto optimal. Fourthly, the health insurance agreement could also be called the health insurance contract. The agreement management was the initial stage of health insurance negotiations. Then we could know legal relations with the subject, object and content.
3. Practice Analysis: Comparing with international level, a list of the basic situation of the negotiating parties showed that our health insurer had relatively weak bargaining power, controlling costs means more backward. Inequality resulted some discord factors in the agreement management (the primary form of health insurance negotiations) for the phases of signing agreement and fulfilling agreement that increased transaction costs and reduce the health insurance fund efficiency. Combined with international research, the thesis focused on the market concentration impact on the health care negotiations, and put Hubei empirical research as an object to confirm. The medical services industry in Hubei Province reached 67.82 percent of market concentration, indicating a high degree of market concentration.The author suggested that public hospitals should be separated regulating and running of health care organizations and the government should set up third-party monitoring mechanism to improve the efficiency of health care negotiations. Finally, in this part of the combination of health insurance status of the negotiations SWOT analysis was made. The atuthor found that the reality of health care bargaining was WO construction and development in the environment. It was urgently needed to improve the internal environment, external environment by using the opportunity and overcoming the disadvantage.
4. Game model: Based on the general analysis of game theory combined with the characteristics of health insurance negotiations, a theoretical model was successfully built. First of all, health care payment was the core of the negotiations with the hospital. Under certain single payment method or combined method in a payment, it was the primary problem in health care negotiations to solve that how to achieve a win-win status between health insurance and hospitals and control the balance of interests in health care costs. Proposal to change the current dynamic game for the static game, could be achieved while maximizing health insurance and hospital benefits. Secondly, the negotiations in accordance with international classification, health care bargaining model could be divided into two categories: individual negotiation model and collective bargaining negotiation model. Individual negotiation model: if they recognized the hospital vicious competition for the long-term results and chose not to control cost, they were bound to earn not any more income.Thus for the hospitals their cooperation was the best option and it was a result of cooperative game non-zero sum game. Collective bargaining model model: bilateral monopoly model and moral hazard model indeed. bilateral monopoly model showed that the rational choice was combined them together into cooperation organization. Because hospital association of moral hazard could cause the loss of the hospital, It may be prevent moral hazard and reduce loss of interest in various hospitals with threatening by the collective behavior of the hospital association. Finally, combined with new health reform-oriented, non-profit health care negotiations would be the main model for hospitals to start exploring the design of non-profit hospitals health insurance transactions. Through modeling, under the total budget conditions, the policy makers should prevent non-profit hospitals to concentrate on providing more high-quality medical services in health care by ignoring the number of cases. To stimulate insufficient incentives for the number of medical problems, the advice may be "by service unit" . Health care payment would form a combination of a more rational health care transactions.
5. Case study: According to the aformentioned theory and surveies about sample areas, typical cases were selected and analyzed in-depth to interpretate construction and negotiation mechanism development. CaseⅠ, Zhenjiang was the first pilot city for the medical insurance system reform assigned by State Council. Some experiences were well summed up in the index fund budget and final accounts and settlement processes , quality controling of medical services, and buying medical services for a great quantity. CaseⅡdescribed negotiation mechanism the details by comparing the Zhenjiang’s policy with Chengdu’s. CaseⅢwas a dynamic health care negotiations. The new agreement would cause hospital behavior change on the next round of negotiations with the policy implications. In this part of the study, time series was used to analyze changes in behavior as an example to illustrate the hospital behavior for payment changes in a county hospital. The study found: Though health care payment paid by the project from the bed at a charge to press, there was no significant increase in medical costs and others except for medicine costs down. Negotiate payment and other important and timely attention should be given to changing circumstances in order to fast dynamic response. CaseⅣ, In certain large hospital (star hospital) health insurance did not start because the negotiations and the adverse selection from the reality of theoretical analysis.The author suggested that if health care organizations to participate in medicare as to whether non-mandatory, large hospitals would give the insured people and the different objects, different services to adopt price discrimination to maximize profits.
6. Practice rules:For the current medical insurance system reform dilemma and the urgent need to push health care negotiations from the theory to health care negotiating practice a set of workable rules should be constructed. Through theoretical and empirical analysis, the system made workable rules of practice of health care negotiations. Established specific objectives: optimal allocation of medical resources, medical services and medicines to effectively control costs. Basic principles: the principle of maximizing the interests of the insured person, a fair balance between efficiency priority, multi-win-win physician-patient-insurer. The thesis showed the initial framework for health insurance negotiations, from the preparation stage, formal phase of negotiations, an agreement to perform stage, regulatory and other aspects of the new requirements. Based on the above discussion, a guideline named " Summary on mechanism for building guidelines for health insurance negotiations"was formatted. Finally, guidelines for negotiating mechanisms did recognition of the extent of health care experts. A higher degree percent of overall recognition were 80, and the reasons for its non-recognition are also analyzed and put corresponding countermeasures.
7.Countermeasures to construction of health insurance negotiations: Learning from international experience, under the background of health reform in our country and our national conditions, corresponding countermeasures and suggestions was put forward from three levels among the system, organization and individual level. On the system level, a good top-level design includes "precise positioning, targeted", "scientific design ","strategic control","the implementation of place". On the organizational level, health care institutions to new ideas, the introduction of competition, and medical institutions To re-positioning, and the power to integrate, the negotiations to increase awareness and motivation.On the individual level, the moral hazard of medical practitioners must be controlled and enrollment rate of insured persons should be enhanced in the negotiations besides that the insured person should accept the main measure of education.
Conclusions
1. Based on situation analysis of the negotiating parties, it showed that the bargaining power of health insurer was weaker and means of controlling costs was lagging behind. As a result, a high degree of market concentration in health care field caused public hospitals showing monopoly-oriented.
2. After negotiations SWOT analysis, the construction of the mechanism of health care negotiations lay in a WO environment. That’s to say, it was urgent to improve the internal environment. WO measures must to be taken by using better opportunities and overcoming disadvantages.
3. If we changed the static game of the health insurer and medical institutions into dynamic game, these two parties could achieve maximizing revenue at the same time under certain conditions.
4. For non-profit hospitals as the main, the combination payment method may be reasonable including "by service unit" and "globe budget ".
5. Whether individual or collective bargaining negotiation, it needed to change non-cooperative game into cooperative game in order to ultimately achieve Pareto optimality.
6. Negotiating workable rules of practice was made systematically. Guidelines summary for building health insurance bargaining was formed initially. And after qualitative and quantitative arguments, the outline was widely recognized and could try to implement.
Innovations and merits
Theoretical innovation: Social health insurance bargaining theory research and practice had just started so that it urgently need to study. Based on the negotiation mechanism in the clear substance, the study formed the basic theoretical framework of negotiations mechanism and developed rules of practice in line with our national conditions.
Innovation of methods: market concentration method was used to position the negotiating parties. Advanced SWOT analysis was identified for the development of health insurance status of the negotiations and strategies. As an empirical study, time series analysis method was adoped to track the hospital behavior after payment reform medical practices. Health insurance negotiation game of two hospitals combining behavioral synthesis modeling was constructed. These methods overcome the traditional focused on one aspect of health insurance by the limitations of methods. They could simulate the process closer to the actual process and the results were more stable. Therefore we could get more credible conclusions.
Policy value: Based on China's realities, with reference to the general rules of negotiation mechanisms of the development of international health insurance, the study established a scientific framework for health care negotiation mechanism and developed appropriate rules of practice. These above had important practical value for the smooth implementation of the national health insurance negotiation mechanism. The study was consisted with rich quantitative data of health insurance negotiations. The current reality was analyzed from various views for formulation of policy-making departments to provide health insurance program policy basis for negotiation mechanism.
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