定额结算下保险医疗费用支付制度安排

医疗保险机构与医院实行定额结算后，医院可通过分科定额结算办法将价格风险下移给科室，促使科室主动控费。而这种制度下，科室将通过牺牲患者利益实现自身效用；若医院按按实结算办法与科室结算医疗费用，则可在一定程度上解决上述问题。本文将针对按实结算办法建立数学模型，确定科室进行合理医疗的费用区间，并通过此模型说明按实结算下，科室通过均衡医患博弈，可在同时保证医院与患者双方利益的基础上有效地控制医疗费用。

Arrangement for the Payment System for Medical Expense under the System of the Quota Settlement

Under the system of the quota settlement of the hospitalization between medical insurance institutions and designated hospitals in the basic medical insurance,hospital can take the way of settlement according to a fixed fees with its clinical departments to transfer the price risk to its clinical departments,thus the clinical departments can be urged to control the medical expenses on their own initiative.However, the clinical departments will sacrifice the interests of patients to realize their own effectiveness under this system;Also,hospital can take the way of settlement according to practical fees with its clinical departments and then the problems discussed above can be solved to a certain extent under this new system.A mathematical model to the new system was established in the paper to determine the fees interval under clinical departments＂ reasonable treatment under the new system,also,the paper wiU use the model to illustrate that the clinical departments can cotrol the medial expenses effectively on the basis of ensuring the interests of both the hospital and patients through balancing the game between hospital and its patients.