Research On The Reform Of Medical Insurance Payment System And Its Effect Evaluation

It is of great significance to study the reform of the medical insurance payment system.The medical insurance payment system refers to the system in which medical insurance institutions allocate and use medical insurance funds to medical service institutions.The core of the medical insurance payment system is the medical insurance payment method,which also includes the regulatory measures for medical insurance payment.The medical insurance payment method is an important measure for the implementation of cost management for medical service institutions,which helps to regulate their service behavior and ensure the effective operation of the medical insurance system.The goal of the reform of the medical insurance payment method is to control the unreasonable growth of medical expenses while ensuring the quality of medical services.Since the 20 th century,the problem of rapid growth of medical expenses has hindered the sustainable operation of the medical insurance system of various countries around the world.An important factor comes from the moral hazard of medical service institutions,that is,medical service institutions use excessive medical treatment in the process of providing medical services.Inflated medical expenses.In this context,the cost control of medical service institutions has become the trend of medical insurance reform in various countries in the world.Since the establishment of the social medical insurance system in China in the early1990 s,the breadth and depth of medical insurance coverage have continued to increase,but the medical insurance fund has always been facing expenditure pressure.Therefore,China proposed the reform of the medical insurance payment system in the late 1990 s.The goal is to find a medical insurance payment method that can control the growth of medical expenses and ensure the quality of medical services.Under the guidance of national policies,China's reform of medical insurance payment methods has achieved phased reform results,and new problems have also arisen.Therefore,it is necessary to conduct systematic analysis and research on the reform and effect of China's medical insurance payment method,and make policy recommendations based on this.This dissertation takes the reform of the medical insurance payment system as the main research object.Through combing and researching the relevant literature on medical insurance payment reform at home and abroad,it is found that domestic researchs on the theoretical study of moral hazard in medical institutions in China,the theoretical study of medical insurance payment methods,the empirical analysis of the effect evaluation of medical insurance payment method reform,the theoretical research of medical insurance payment supervision and the reference of foreign medical insurance supervision organization system are insufficient,so this dissertation will focus on the above five aspects,according to the combinations of qualitative analysis and quantitative analysis,theoretical analysis and empirical analysis,domestic analysis and foreign analysis,of the related issues of the reform of the medical insurance payment system.The research ideas of this dissertation are as follows: This dissertation first introduces the various medical insurance payment methods on the basis of theoretical proof of moral hazard in medical insurance.Subsequently,a theoretical model of hospitalization payment for urban employee medical insurance is established,and the diagnosis and treatment behaviors and problems of medical service institutions under different payment methods were analyzed,and corresponding solutions were proposed and proved.Then,based on the above theoretical model conclusions,using the natural experimental data of the reform of the medical insurance payment method of a certain province,conduct empirical analysis through the mixed model,static individual effect panel model and breakpoint regression model to comprehensively evaluate the efficiency of medical services and medical expenses,and put forward policy recommendations.Finally,through dynamic evolutionary game analysis to prove the importance of medical insurance payment supervision,combined with the experience of foreign medical insurance payment supervision systems,put forward ideas for improving China's medical insurance payment supervision system.This dissertation will conduct a more comprehensive and specific theoretical analysis and practical evaluation of the reform of China's medical insurance payment method,and provide policy recommendations for further improving China's social medical insurance system.This dissertation consists of six chapters,the specific research content and conclusions are as follows:Chapter One,Introduction.Introduce the research background and significance of this dissertation,and define the basic concepts of the research object.Review the domestic and foreign literature in the field of medical insurance.Sort out the basic ideas and research content,and explain the research methods,innovations and deficiencies.Chapter Two,Moral Hazard of Medical Service Institutions and Reform of Medical Insurance Payment Methods.The moral hazard of medical service institutions is proved by a theoretical model,and combined with the actual situation in our country for economic explanation,the conclusion is as follows:First,the unreasonable medical behavior of the supplier inducing demand is related to the profit of reasonable medical service.When the total number of reasonable medical behaviors and the amount of per capita medical services generated or the corresponding profits decrease,it will cause the increase of unreasonable medical behaviors of medical service institutions.Therefore,when reasonable medical profits have fallen,corresponding compensation must be given to medical service organizations to avoid unreasonable medical behaviors that induce demand for medical service organizations to make up for the decline in profits.In recent years,China has deepened the reform of "Separation of Medical Care and Medicines".After public medical service institutions canceled the drug markup in 2017,medical service institutions cannot make profits from prescribing drugs,and reasonable medical profits will decline,which may cause the moral hazard of medical service institutions to rise.Therefore,while solving the problem of "Medicine Raises Medical care",China should also improve the compensation mechanism of medical service institutions,increase the pricing level of medical services,compensate for the loss of profits of medical service institutions and strengthen the linkage between the reform of the medical insurance payment method and the compensation method of medical institutions.Second,the unreasonable medical behavior of the supplier to induce demand is affected by the government's allocation of medical and health services.When the government's financial appropriation for health services decreases,medical service organizations will increase the supply-side demand-induced unreasonable medical behaviors in order to compensate for the loss of profits,so as to make up for the increase in profits from unreasonable medical practices to compensate for the decrease in profits from reasonable medical practices.This conclusion provides a theoretical basis for China to increase the financial allocation of health services.Compared with developed countries,China's financial investment in health care is still insufficient.Therefore,in the process of deepening the reform of the medical security system,the government also needs to continue to increase financial investment in medical and health care,to ensure that medical service institutions achieve a balance of revenue and expenditure during their operation,and to encourage medical service institutions to standardize medical behavior.Third,the unreasonable medical behavior of the supplier inducing demand exists due to the different profits of the medical behavior itself.High-profit irrational medical behaviors are more induced than low-profit irrational medical behaviors,and medical service organizations are more likely to choose unreasonable medical behaviors that produce high profits for demand induction.This conclusion explains the excessive medical behaviors in the operation of China's medical insurance system,such as prescribing a large number of imported drugs and frequently conducting high-priced medical examination items.Therefore,in China,we should strengthen the "Three-medicine Linkage" of the reform of the medical insurance system,the reform of the health system and the reform of the drug distribution system,implement the reform of medical service charges,and further standardize medical service behavior.Fourth,Restricting the moral hazard of medical service institutions through the reform of medical insurance payment methods is an inevitable choice for deepening the reform of China's medical and health system.At present,the mainstream international medical insurance payment methods can be generally divided into post-payment system and pre-payment system.Throughout the history of the reform of medical insurance payment methods worldwide,the post-payment system based on service items is gradually decreasing.The reform of payment methods includes total prepayment system,per capita payment system,single disease payment system,disease diagnosis group payment system,bed-day payment system,and value-based compensation system.Different prepayment systems have their own advantages and disadvantages,characteristics and scope of application.On the whole,the reform of medical insurance payment methods is an effective way to control the unreasonable growth of medical expenses,control medical service behavior,and adjust the allocation of medical resources.This chapter lays the foundation for further research in chapters Three,Four and Five.Chapter Three,Theoretical Model Analysis of Medical Insurance Payment Methods.Combining with China's specific national conditions and the relevant policies of payment method reform,establish the utility function of the social medical insurance system itself and medical service institutions,patients,and medical insurance institutions,and solve the optimal level of medical service institutions' diagnosis and treatment behaviors under the condition of complete symmetry of information.Analyze the diagnosis and treatment behavior and incentive mechanism of medical service institutions under five payment methods under the condition of information asymmetry,and prove the common moral hazard problems in medical insurance and propose solutions with theoretical basis.Based on the above analysis,the conclusions and policy recommendations for implementing different payment methods in China's social medical insurance system are drawn:First,the optimized path of China's payment method reform.1.Optimize the amount of medical services per capita.(1)The Fee For Service System will inevitably lead to the problem of excessive medical services,so it is imperative to reform the payment method;the reform of the payment method can alleviate the problem of excessive medical services,but at the same time may lead to the problem of insufficient medical services.(2)In order to achieve the optimal level of per capita medical services after the payment method reform,the self-payment ratio needs to be set reasonably: under the Prospective Payment System,the Capitation Payment System,and the Diagnosis Related Groups Payment System,the self-payment of all diseases needs to be set to a uniform value.This means the need to reform the "deductible and capped lines" and "segment reimbursement" systems,so that the self-payment ratio for all diseases will not decrease with the increase in the amount of medical treatment;under the Flat Rate Payment System,we need to set different self-payment ratios for different diseases,and adjust the system parameters of "deductible line and capped line" and "segment reimbursement" to approach the optimal level.(3)On the premise of keeping the optimal amount of medical services per capita unchanged,the main way to reduce the burden of medical expenses paid by individuals is to reduce the profit-seeking preference of medical service institutions;under the bed-day-pay system,it is also possible to increase the payment by the pooled fund or reduce the cost of medical services.(4)When the amount of medical service per capita reaches the optimal level,there should be a reverse relationship between the adjustment of the medical service mark-up rate and the self-payment ratio.The system parameters of the medical service mark-up rate need to be adjusted with the parameter of self-payment ratio at the same time,and the adjustment direction is opposite.2.Optimize the doctor's effort.(1)Under the five payment methods,there is a general problem of insufficient doctors' efforts.Therefore,the reform of medical insurance payment methods cannot change the doctor's efforts.(2)Only when medical service institutions attach the same importance to public welfare and profitability,can doctors achieve the optimal level of effort.Therefore,it is necessary to make the profit-seeking preference of medical service institutions equal importance of public welfare and profitability through ideological education or institutional supervision.3.Optimize the number of patients treated.(1)Under different payment methods,the number of patients treated always depends on the positive or negative effect of treating a single patient.(2)Under the four payment method reform systems,the Total Prepayment System and the Capita Payment System are most likely to cause insufficient number of patients to be treated.Therefore,for areas that need to strengthen the "wide coverage" social medical insurance goals,the Prospective Payment System and the Capitation Payment System should be carefully implemented.For areas that focus on conserving medical resources and preventing abuse of the pooling fund,priority can be given to the implementation of the Prospective Payment System and the Capitation Payment System.(3)In order to achieve the optimal number of patients treated for all diseases,under the reform of the four payment methods,it is necessary to set different self-payment profit rates for different diseases.(4)On the premise of maintaining the optimal number of patients treated,when the profitability of medical service institutions increases or the cost of medical services rises with the advancement of medical technology,the self-payment ratio should be reduced accordingly under the reform of the four payment methods,reduce the burden of personal medical expenses.(5)Under the Diagnostic Related Groupings and Bed-Day Payment System,increasing the fixed amount of disease or bed-day paid by the pooling fund will increase the payment pressure of the pooling fund,but reduce the burden of medical expenses paid by individuals.(6)Under the reform of the four payment methods,when the number of treated patients reaches the optimal level,there should be a reverse relationship between the adjustment of the medical service mark-up rate and the self-payment ratio.Therefore,the adjustment of the system parameters of the medical service mark-up rate needs to be carried out simultaneously with the adjustment of the system parameters of the self-pay ratio,and the adjustment direction is opposite.Second,the unreasonable distribution of medical resources in the reform of payment methods in China.1.The problem of unreasonable resource allocation for per capita medical services.Under the Prospective Payment System,the Capitation Payment System,and the Diagnosis Related Groups Payment System,there is a problem of unreasonable resource allocation for the amount of medical services per capita.The amount of medical services per capita for severe diseases is lower than that for mild diseases.In order to obtain more medical services per capita for severe diseases,the self-payment ratio can be reformed so that the self-payment ratio for severe diseases is higher than that for mild diseases.2.The problem of unreasonable allocation of resources for doctors' effort.Under the five payment methods,the problem of unreasonable allocation of resources for doctors' effort is common,and the doctor's effort invested in the treatment of patients with severe diseases is lower than that of patients with mild diseases.In order for doctors to devote more time and energy to severe diseases,it is necessary to compensate doctors for their efforts,and the marginal growth rate of income compensation for doctors' efforts is higher than the marginal growth rate of negative effects of doctors' efforts,which improves the rationality of the allocation of doctors' effort among diseases.Third,the transfer of medical service items outside the scope of medical insurance reimbursement in the reform of China's payment method.Under the reform of the four payment methods,there is a problem of the transfer of medical service items outside the scope of medical insurance payment(transfer to outside the medical insurance catalog).After the implementation of the payment method reform,the mechanism of setting an upper limit on the medical expenses paid by individuals will be implemented at the same time,which can avoid the transfer of service items outside the scope of medical insurance reimbursement.At this time,medical service institutions will independently adjust the amount of medical services per capita or the number of patients treated so that the expenses paid by individuals just reach the upper limit of payment.Therefore,it is necessary to cooperate with other mechanisms to guide the diagnosis and treatment behavior of medical service institutions to the optimal level.At this time,if it is necessary to improve the utility of medical service institutions,it is only necessary to increase the upper limit of medical expenses paid by individualsFourth,refusal to patients in the reform of payment methods in China.1.Refusal to diagnose severe patients.When medical resources are limited,the phenomenon of refusal to diagnose severe patients is common under the five payment methods.In order to avoid the phenomenon,consider the payment methods of Diagnosis Related Groups Payment System(DRGs).In the setting the quota of the disease diagnosis group,the marginal profit of the medical service organization increases as the severity of the same disease and the rate of increase is equal to the decrease in marginal output,so that the average utility of the per capita medical service for severe patients is equal to that of mild patients.2.Refusal to diagnose rare patients.When medical resources are limited,there is a common phenomenon of refusal to rare patients under the five payment methods.In order to avoid the occurrence of such problems,a compensation mechanism for doctors' effort can also be established,so that the average utility of treating rare patients is equal to that of common patients.Specifically,according to different profit-seeking preferences,it is necessary to set the marginal growth rate of doctors' effort income.When the profit-seeking preference is the highest value,the marginal growth rate of the doctor's effort income is equal to the marginal growth rate of the negative effect of the doctor's effort.When the profit-seeking preference is to balance output and profit,the marginal growth rate of income of doctors' effort needs to offset the marginal negative growth rate of marginal output and the marginal positive growth rate of negative utility of doctor's effort.3.Refusal to diagnose patients with serious diseases.When medical resources are limited,under the Prospective Payment System and the Capitation Payment System,there is a phenomenon of refusal to diagnose patients with serious diseases.The solution to this problem is to implement a reform of the self-payment ratio so that the self-payment ratio of serious diseases is higher than that of light diseases.Chapter Four,An Empirical Analysis of China's Medical Insurance Payment Methods.First,we sorted out the policy requirements for the reform of medical insurance payment methods issued in China from the 1990 s to the present.Secondly,based on the economic conclusions in Chapter 3,we used the large sample data of the natural experiment of the Prospective Payment System of a provincial employee medical insurance in 2013,through the Mixed model,the Static Individual Effect Panel Model and the Regression Discontinuity imodel,test the impact of the total prepayment system reform on the efficiency of medical services and medical expenses,and put forward conclusions and recommendations:First,the conclusions and suggestions of the reform of the total prepayment system on the efficiency of medical services.1.After the reform of the total prepayment system,the average hospital stay has dropped significantly,especially for severe diseases,which indicates that the efficiency of medical services has been improved.It is worth noting that it is necessary to set minimum hospitalization days,basic inspection items,and other per capita medical service standards for different diseases,and set strict patient discharge standards to ensure that over-medical treatment is restricted while avoiding insufficient medical treatment.2.(1)The total prepayment system did not lead to a general decline in hospitalizations.The reason is that in the total prepayment system reform of a provincial employee medical insurance,the number of hospitalizations in the previous year was the main factor in determining the total budget.Therefore,in order to increase the total payment received in the next year,medical service organizations need to increase the number of hospitalizations in the current year.This factor restricts the behavior of medical service organizations to reduce the number of patients treated in the theoretical model.This shows that a scientific and reasonable way to determine the total budget is the focus of the total prepayment system.By adding the consideration of the number of inpatients in the process of determining the total budget,it is possible to effectively avoid the phenomenon of refusal of patients.(2)The total prepayment system has not led to medical behaviors that induce an increase in the number of hospitalizations for mild diseases.We should continue to strengthen the supervision and management of the medical service process through big data monitoring and institutional measures.(3)The reform has significantly reduced the growth rate of hospitalizations for severe diseases.The overall planning fund should compensate medical institutions for additional costs for receiving severe disease cases to ensure that medical service institutions do not incur losses due to treatment of severe disease cases,and at the same time guarantee patients with severe diseases can get normal hospitalization and reasonable medical services.(4)The reform of the total prepayment system cannot solve the problem of refusal to diagnose critically ill patients and rare patients.Therefore,it is necessary to effectively supervise the medical process of critically ill and rare diseases through medical insurance supervision methods.Second,conclusions and suggestions on the reform of the total prepayment system on medical expenses.1.The total prepayment system generally reduces the costs paid by the pool fund,and has a more obvious impact on common diseases and mild diseases,indicating that it has significantly reduced the medical expenses paid by the pool fund for most common diseases.In the process of China's deepening of the reform of the medical security system,the budget management method of the total prepayment system should continue to be implemented,which will help solve the problem of the medical insurance fund's "revenue not offset expense" and ensure the long-term operation of the medical insurance system.2.The total prepayment system generally increases the medical expenses paid by individuals,and has a more obvious impact on the increase of medical expenses paid by individuals for severe,rare,and critically ill diseases.While implementing the total prepayment system,in order to prevent medical service organizations from transferring medical service items to individuals outside the scope of medical insurance payment,the payment scope of the overall fund should be expanded,and the proportion of personal medical expenses should be reduced,thereby reducing medical services.Institutions provide incentives to make profits for medical service items outside the scope of payment to avoid unreasonable growth in medical expenses paid by individuals,and to better play the role of mutual assistance and mutual assistance of the social medical insurance pooling fund.At the same time,it is necessary to continue to improve the critical illness insurance system to alleviate the personal medical burden caused by major diseases.Chapter ?,Supervision Analysis and Experience Reference of Medical Insurance Payment.First,it introduces the current situation of China's medical insurance supervision,and explains the deficiencies of China's medical insurance supervision system.Secondly,the dynamic evolutionary game model proves the important role of medical insurance supervision,and proposes the experience of foreign medical insurance supervision system for our country.conclusion as below:First,the dynamic evolutionary game model of medical insurance payment supervision shows that only when medical insurance institutions implement powerful fines and supervision actions,can medical service institutions be prevented from entering a stable state of long-term use of unreasonable access to medical insurance funds;and the prerequisite for insurance institutions to implement supervision is the need to reduce the inspection cost of payment supervision.Therefore,the establishment of a medical insurance institution supervision system is an inevitable choice to ensure the effective operation of the medical insurance payment system.Second,improving the medical insurance payment supervision system is of great significance to improving the efficiency of medical insurance payment supervision.Drawing on the experience of the medical insurance regulatory organization system and rules setting in Germany,the United States,and the United Kingdom,China should establish an independent social medical insurance regulatory agency,set up a professional agency for auxiliary supervision,establish a social medical insurance litigation handling agency,realize the provincial-level coordination of medical insurance supervision and implement institutional regulatory measures.Chapter ? Evaluation Conclusion and Research Outlook.Summarizes the main conclusions of this dissertation on the reform of medical insurance payment methods and the effect evaluation,and prospects for further research.The innovation achieved in this paper includes five aspects:First,improve the moral hazard model of China's medical service institutions and put forward corresponding suggestions.Domestic scholar Li Junshan(2008)proposed a theoretical model reflecting China's actual supplier-induced demand based on the Evans' utility maximization goal hypothesis.This dissertation has improved the model and applied the inferences in the reform of the medical insurance system to explain China's sources of moral hazard in medical insurance and put forward corresponding policy recommendations.Second,a relatively complete theoretical model of hospitalization payment for the basic medical insurance for urban employees in China has been established.Many domestic scholars have conducted qualitative analysis on the pros,cons and impacts of medical insurance payment methods,but without the support of theoretical models,it is impossible to draw rigorous conclusions,and it is difficult to draw theoretically based optimization paths.A few scholars have established a theoretical model of medical insurance payment,but the model setting is too simple and does not fully consider the actual situation of China's medical insurance system.The model in this paper reflects the specific implementation of the basic medical insurance for urban employees in China,and can draw conclusions and policy recommendations applicable to the basic medical insurance for urban employees in China,which has high practical significance.The key points of the model include: First of all,according to China's "combination of accounts" payment method,the medical expenses paid by the pooling fund and the medical expenses paid by individuals are examined at the same time.Second,analyze the heterogeneity of the impact of different medical insurance payment methods on different diseases.Third,a comprehensive analysis of the four reform methods required to promote the Prospective Payment System,the Capitation Payment System,the Diagnosis Related Groups Payment System,and the Bed-to-Day Payment System that China's policies require.Fourth,model the problems of unreasonable distribution of medical resources in the basic medical insurance system for urban employees,the transfer of medical service items outside the scope of medical insurance payment,and patients who refuse to be diagnosed with a model,and propose and prove corresponding solutions.Fifth,derive how to make the diagnosis and treatment behavior reach the optimal level by setting the system parameters,so as to propose a path to optimize the basic medical insurance system for urban employees in China.Sixth,considering the profitability of medical service institutions in the basic medical insurance system for urban employees in China,the proportion of personal self-payment and the low medical service mark-up rate,etc.,draw conclusions and policy recommendations applicable to the basic medical insurance for urban employees in my country through theoretical models.Third,use breakpoint regression and other methods to conduct a scientific and comprehensive empirical research on the effect of China's medical insurance payment reform.Regarding the effect of China's medical insurance payment reform,most scholars only use qualitative research or simple data analysis,which is not enough to prove the real effect of the reform.This paper conducts an empirical test of the mixed model,static individual effect panel model and breakpoint regression model for the reform effect of the total prepayment system of the provincial employee medical insurance in a certain province.The breakpoint regression model is currently a wide range of policy evaluation methods,which can solve endogenous problems and achieve good test results.At present,the research on the reform of medical insurance payment methods at home and abroad has not adopted the breakpoint regression method.This dissertation will try to use breakpoint regression for empirical test,and provide ideas and methods for reference for the evaluation of the effect of medical insurance payment method reform.In addition,this dissertation uses the conclusions of the theoretical model in Chapter 3 as the research hypothesis for empirical analysis,which has scientific theoretical basis.At the same time,this dissertation conducts a comprehensive research and analysis on the impact of payment method reform on medical service efficiency and medical expenses,and conducts an objective and comprehensive evaluation of the reform effect.Fourth,establish and analyze the dynamic evolution model of the medical insurance supervision system.As a common analysis method in evolutionary economics,dynamic evolutionary game theory is suitable for analyzing the influencing factors of the formation of institutions and explaining its formation process.In recent years,more and more scholars have put forward the importance of medical insurance supervision based on practical experience,but they have not proved the necessity and reason of medical insurance supervision through theoretical models.Therefore,this paper adopts the dynamic evolution game model to analyze the dynamic evolution process of the medical insurance institution supervision or non-regulation,the medical service institution violation and non-violation,so as to prove the role of medical insurance supervision in preventing the medical service institution from implementing violations and seek the premise that medical insurance supervision can really play a role.Fifth,select foreign medical insurance systems with social medical insurance attributes as reference objects for improving China's medical insurance supervision system.This paper selects German Statutory Medical Insurance,American Medicare and British National Medical Insu...