从经济学视角谈公立医院管理体制改革

我国公立医院管理体制经历数次改革,虽取得一些进展,但仍存在诸如商业贿赂、可及性低、病人看病难、设备诊断费高、医药费贵、大诊断、大处方等一系列问题。本文从经济学视角对公立医院服务体系的构成要素进行不同性质的理论区分,明确市场和政府在公立医院服务供给中的界限,在此基础上提出以医疗费结算为核心的公立医院管理改革及医疗服务体系改革措施。     

论医改后公立医院如何实行全成本核算

随着我国社会经济的快速发展和医疗卫生体制改革的不断深化和完善,医疗市场竞争日趋激烈。目前"优质、高效、低耗"的运作模式已被公认为是医院可持续发展的主要方向。医院在国家逐步减少补助的情况下,只有增强自身的积累和发展能力,才能继续生存和发展。所以本文针对2009年公立医院改革,提出只有实行全成本核算,千方百计降低医疗服务成本,提升医院竞争力,才能适应竞争激烈的医疗市场,从而走向可持续发展之路。     

医保支付之限额付费方式——基于湖南蓝山、桑植两县的调查

医疗保险支付方式是医疗保险机构对医、患(参保人)的付费方式。支付方式改革是当今世界很多国家医改的核心与难题。湖南蓝山县和桑植县推行了限额付费方式改革,参合农民在乡镇卫生院看病就医,门诊、住院费用付费限额内如实自付,超额部分由新农合基金全额报销,同时,对卫生院实行诊疗人次费用、住院床日费用以及总费用控制,对医生实行绩效工资制。创造了有别于"全民免费医疗"的"全民限费医疗"新模式。推广这种新模式的路径是:明确医疗服务的享受主体、服务主体及范围,科学制定总额预付标准,完善监管机制,建立医疗服务与社会医疗保险二位一体的新体制等。     

How do low-income enrollees in the Affordable Care Act marketplaces respond to cost-sharing?

The Affordable Care Act requires insurers to offer cost-sharing reductions (CSRs) to low-income consumers on the marketplaces. We link 2013–2015 All-Payer Claims Data to 2004–2013 administrative hospital discharge data from Utah and exploit policy-driven differences in the actuarial value of CSR plans that are solely determined by income. This allows us to examine the effect of cost-sharing on medical spending among low-income individuals. We find that enrollees facing lower levels of cost-sharing have higher levels of healthcare spending, controlling for past healthcare use. We estimate demand elasticities of total health care spending among this low-income population of approximately −0.12, suggesting that demand-side price mechanisms in health insurance design work similarly for low-income and higher-income individuals. We also find that cost-sharing subsidies substantially lower out-of-pocket medical care spending, showing that the CSR program is a key mechanism for making health care affordable to low-income individuals.     

医院物价管理中自律管理的思考

医疗费是人们生活中最重要的开支之一,而随着人们对身体健康的日益关注,医疗费在人们生活开支中所占的比例也逐年增多.“看病贵”依然是我国面临的重要民生问题,而加强医院物价管理,推行自律管理,能减少或避免医院乱收费的现象,对规范医院收费行为有着重要的作用,可有效解决人们“看病贵”等民生问题,切实地维护广大医疗消费者的利益.本文深入医院物价管理的实践中,从自律管理角度探讨新形势下医院如何更好地开展物价管理工作,为我国医疗事业的健康、稳定发展提供一定的参考借鉴价值.     

Health information technology and patient outcomes: the role of information and labor coordination

Health information technology (IT) adoption, it is argued, will dramatically improve patient care. We study the impact of hospital IT adoption on patient outcomes focusing on the role of patient and organizational heterogeneity. We link detailed hospital discharge data on all Medicare fee‐for‐service admissions from 2002–2007 to detailed hospital‐level IT adoption information. For all IT‐sensitive conditions, we find that health IT adoption reduces mortality for the most complex patients but does not affect outcomes for the median patient. Benefits from health IT are primarily experienced by patients whose diagnoses require cross‐specialty care coordination and extensive clinical information management.     

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。     

Designing a guideline-based utilization management program

Many public and private organizations are developing and publishing clinical guidelines to assist health care providers and patients in making appropriate medical decisions. Unless clinical guidelines are part of a well-designed managed care program, they have little effect on physician practice styles. This article explores integral components of an effective guideline-based utilization management program. Initial evaluation of this program suggests that, as part of a well-designed utilization management program, clinical guidelines can inform patients and physicians, and create appropriate incentives for effective health care delivery.     

医保医疗款会计核算方法探讨

现阶段,我国基本医疗保险覆盖率达95%,全民医疗保险的制度框架已经建立,医保业务收入占业务收入的实际比重越来越大,未来或将取代现金医疗收入成为医院医疗收入核算的主体,因此,对这部分医保医疗款如何更清晰地核算成为了医院财务管理工作中一个重要的环节,正确、清晰地对这部分医疗收入进行会计核算,会有利于加强医院对医保医疗款的管理。     

Hospital use behaviors and associated costs in a health insurance organization, Japan

Physicians are known to play an important role in the rise of health care costs. But patients--the other side of the chain of health care systems--have been given little attention. The present study utilized the outpatient claims (in the belief that the outpatient hospital visits are mainly decided by the patients) from a health insurance organization in Japan (the Fukuoka Prefecture public service mutual aid association for government employees who serve in small cities, towns, and villages) to analyze the employee behaviors in the use of hospital care and the costs associated with these behaviors. Number of diseases diagnosed for an employee, number of claims an employee submitted for one disease, number of hospitals an employee visited, number of claims an employee had from one hospital, and the total number of claims an employee submitted were used to describe the hospital use behaviors. Results showed that some employees exhibited unusual behaviors, characterized by having an extremely large number of diseases diagnosed, visiting a large number of different hospitals, having a large number of claims, etc. Higher medical expenditures were associated with such behaviors. The findings of this study suggest that the patients' role in the rise of health care costs cannot be ignored, and cost-containment strategies targeting modification of patient behaviors in the use of hospital care may prove to be very useful.     

The effects of hospital ownership on medical productivity

To develop new evidence on how hospital ownership and other aspects of hospital market composition affect health care productivity, we analyze longitudinal data on the medical expenditures and health outcomes of the vast majority of nonrural elderly Medicare beneficiaries hospitalized for new heart attacks over the period 1985-1996. We find that the effects of ownership status are quantitatively important. Areas with a presence of for-profit hospitals have approximately 2.4% lower levels of hospital expenditures, but virtually the same patient health outcomes. We conclude that for-profit hospitals have important spillover benefits for medical productivity.     

FINANCING SATELLITE OUTPATIENT CARE IN RURAL HOSPITALS

Providing health care to low income or elderly residents of rural areas remains a serious national health care problem in the United States. This case study evaluates an intervention for primary outpatient care to a particular class of patients – veterans – and shows how it can benefit them. Locating the outpatient clinic in a struggling rural hospital makes an outreach by the urban veterans hospital financially feasible and is profitable for the rural hospital.     

信息非对称视角下大学生医保制度的可持续发展：困境与对策

医疗领域信息非对称的特征也深刻地影响着大学生医保制度的发展,校医院医疗服务质量偏低与大学生对自身健康状况过于乐观两方面因素共同作用,导致大学生参保积极性不高,给制度的可持续发展造成了困境,也决定了现行的大学生医保制度只能是＂过渡性质＂的。今后,我国的大学生医保制度如欲实现对＂过渡性质＂的实质性跨越,需以参保宣传、制度建设、机构改革和体系衔接四个方面为突破口,克服困难以推进新医保制度的永续发展。     

Community health care in developing countries

Health care systems in many developing countries have shared characteristics. Government expenditures in poor countries are low for health care. The majority of people cannot easily reach a modern health facility. Most spending is for high-cost curative medicine, e.g., hospitals. Programs are often inefficient in their use of funds. The tragedy of disease in developing countreis is that many of the most serious problems are either preventable or curable by simple, inexpensive, safe methods. About 16 million children under age 5 died in 1979 in developing countries; 5 million of these deaths could have been prevented by immunization against measles, polio, tetanus, diphtheria, whooping cough, and typhoid. Many countries are establishing community-level health care facilities that use community health workers instead of doctors. A 3-tiered program is being adopted in some areas: the community health center, the rural or urban polyclinic, and the referral hospital. The community health center seeks to provide two-thirds of the needed services, including supervision of pregnancy, midwifery, care of new-born children, treatment of endemic diseases, and emergency care for injuries. Early experience has taught that it is more important for the community health worker to have practical experience and the respect of the people he serves than formal education. Improvements in nutrition, hygiene, and sanitation are needed to reach the full health potential of most communities.     

微观经济个体参保行为对医疗费用支出的影响效应研究

本文根据2016年中国家庭追踪调查数据,运用面板数据回归方法和倾向得分匹配法(PSM)研究微观经济个体参保行为对医疗费用支出的影响。研究表明,城镇职工医疗保险参保行为显著提高了医疗总费用和自付费用,城乡居民医疗保险参保行为对降低医疗总费用和自付费用具有一定的积极作用,新农合参保行为显著降低了医疗总费用,对自付费用的降低具有一定的积极作用。运用PSM法解决内生性问题和消除选择性偏差后得到的净效应结果与上述发现基本一致。参保行为与医院等级的交互分析表明,选择社区诊所等基层诊疗机构就诊可显著降低医疗总费用和自付费用,选择综合医院就诊则显著提高医疗总费用和自付费用。此外,参保行为对医疗费用支出的影响具有个体和区域异质性。据此,建议增强基层医疗卫生服务能力,进一步提高统筹层次,推进公共卫生服务均等化。     

试析医疗卫生事业发展的特殊矛盾和我国医改的路径选择

市场经济条件下医疗卫生事业发展面临五大特殊矛盾。现行医疗卫生体制要解决的首要问题是体制、机制创新问题。公立医院改革和医疗保险体制改革相结合,建立以公益性医院为主题的医疗保险职能和公共医疗服务职能相结合的制度统一、全民覆盖、统筹城乡的新型公共医疗服务保险制度,构建政事分开、管办分开、医保基金管用分开的医疗卫生管理体制,是化解现行医药卫生体制蕴藏的内在矛盾,破解我国医改难题的可行的路径选择。     

补充医疗保险对居民消费的影响——来自城乡居民大病保险的证据

促进消费对我国稳定经济增长和构建新发展格局至关重要。本文基于中国家庭追踪调查数据(CFPS),利用地级市层面实施城乡居民大病保险的时间差异,运用双重差分法估计了大病医疗保险对居民消费的影响。结果表明,大病保险使家庭人均消费显著增长了约6%。使用了事件分析法、置换检验、改变回归样本和控制变量等一系列检验后,结论仍保持一致,且这一效果在期初住院率高、储蓄率高以及收入较高的家庭中更明显。进一步地,本文检验了大病保险对居民消费的三种可能影响渠道,发现降低家庭对未来医疗支出风险的预期是大病保险促进家庭非医疗消费进而影响家庭总消费的主要渠道,印证了我国居民对高额医疗支出的担忧是影响消费意愿的重要因素。本文研究对于完善多层次医疗保障体系和促进居民消费具有启示意义。     

论商业保险基础风险原理对建立基本医疗保障制度的适用价值

2009年新医改重大举措不断,它对于我国相对薄弱的医疗保障体系无疑是必需和及时的。本文从理论上初步论述了商业保险基础风险原理对完善建立我国全民基本医疗保障制度的适用价值。通过总结国际医疗保障制度改革及其研究的趋势,论证以医疗保险的基础风险为依据,是实现社会医疗保险预期绩效的基本保证。同时指出定性定量分析我国全民医保的基础风险,才能从根本上找到完善建立相关制度的措施和方法,促进我国医疗保障体系的进一步科学发展。     

Health insurers' use of quality improvement expenses to achieve a minimum medical loss ratio requirement

Health insurer medical loss ratios (MLRs) are the percentage of premium dollar spent on medical claims and healthcare quality improvement expenses (QIEs). QIEs include activities to improve patient health outcomes and safety, reduce medical errors, and prevent hospital readmissions. The Affordable Care Act mandates minimum MLRs in certain health insurance markets lest rebates be paid to policyholders. QIEs are reported in all markets regardless of whether that market is subject to minimum MLR requirements. Using health insurer statutory filings for a sample of group market insurers from 2010 to 2018, we employ a mixed regression discontinuity/regression kink approach to evaluate whether QIEs are used by insurers as a potential strategy for meeting the minimum MLR requirement. We show that health insurers' QIE increase in the loss ratio until meeting the minimum MLR requirement, have a significant discontinuous jump at the threshold, and decrease above the threshold after the introduction of the MLR mandate.     

Does competition under Medicare Prospective Payment selectively reduce expenditures on high-cost patients?

Competition and prospective payment have been widely used to control health care costs but may together provide incentives to selectively reduce expenditures on high-cost relative to low-cost patients. We use patient discharge and hospital financial data from California to examine the effects of competition on costs for high- and low-cost admissions in the 12 largest Diagnosis-Related Groups before and after the Medicare Prospective Payment System (PPS). We find that competition increased costs before PPS, but that this effect decreased afterward, especially inpatients with the highest costs.We conclude that competition and PPS selectively reduced spending among the most expensive patients and that careful assessment of these patients' outcomes is important.