管理医疗模式的影响差异——来自加州医疗救助的经验证据

国际上越来越多的健康保险(医疗保险)采用了管理医疗的方式,目的在于保证健康服务质量并节约成本。尽管该方式在控制成本方面的效果有目共睹,但对于其保证健康服务质量方面的评价则颇为困难。本文使用独特的大样本数据,利用美国加利福尼亚州医疗救助项目(美国最大的公共健康保险之一)从传统按次偿付方式到多种管理医疗模式的转变,来识别不同管理医疗模式对健康服务的使用及服务质量的影响。这对于我国公共健康保险制度(如新型农村合作医疗)的探讨具有一定的借鉴意义。     

Consumer Resistance Against Regulation: The Case of Health Care

Regulation fostering Managed Care alternatives in health insurance is spreading. This work reports on an experiment designed to measure the amounts of compensation asked by the Swiss population (in terms of reduced premiums) for Managed-Care type restrictions in the provision of health care. It finds that restrictions on the freedom of physician choice would require an average compensation of more than one-third of the premium, while generic substitution even meets with a small willingness to pay. Marked preference heterogeneity is an argument against regulation imposing uniformity of contract in Swiss social health insurance.     

Avoiding the mistreatment of bad risks in a democracy: Universal Health Insurance from a constitutional perspective

This paper examines the concept that social insurance for medical care may represent a kind of constitutional choice. The long-term stability of the U.S. Medicare program indicates that such programs are rarely altered. The primary reason postulated for treating subsidized medical insurance as a constitutional choice is to guard against a temporary majority of persons in good health or not at risk for a disease voting to deny benefits for the minority who are at higher risk. It is argued, however, that, although there needs to be constitutional status for social insurance, insurance need not and probably should not take the form of tax-financed equal coverage for all.     

INSURANCE‐INDUCED MORAL HAZARD: A DYNAMIC MODEL OF WITHIN‐YEAR MEDICAL CARE DECISION MAKING UNDER UNCERTAINTY

This study quantifies the moral hazard effect of health insurance on medical expenditure by estimating a dynamic model of within‐year medical care consumption that allows for insurance selection, endogenous health transitions, and individual uncertainty about medical care prices in an environment where insurance has nonlinear cost‐sharing features. The results suggest that moral hazard accounts for 53.1%, on average, of total annual medical expenditure when insured. This estimate is significantly different, and generally larger, than that produced by an alternative model that is representative of the annual medical care decision‐making models commonly found in the literature.     

Complex home care: Part 2- family annual income, insurance premium, and out-of-pocket expenses

Annual costs paid by families for intravenous infusion of home parenteral nutrition (HPN) health insurance premiums, deductibles, co-payments for health services, and the wide range of out-of-pocket home health care expenses are significant. The costs of managing complex chronic care at home cannot be completely understood until all out-of-pocket costs have been defined, described, and tabulated. Non-reimbursed and out-of-pocket costs paid by families over years for complex chronic care negatively impact the financial stability of families. National health care reform must take into account the long-term financial burdens of families caring for those with complex home care. Any changes that may increase the out-of-pocket costs or health insurance costs to these families can also have a negative long-term impact on society when greater numbers of patients declare bankruptcy or qualify for medical disability.     

中国老人医疗保障与医疗服务需求的实证分析

本文采用2005年中国老年健康长寿调查数据库(CLHLS)22省调查数据,建立了中国65岁以上老年人群的医疗服务需求模型,实证分析了医疗保障对老人医疗服务需求的影响。本文的主要结果如下:第一,医保制度对老人医疗服务的影响主要表现在提高就医程度,而非就医选择行为的改变,同时医保制度又明显地促进了老人及时就医率。第二,医保制度对减轻老人家庭医疗负担具有显著作用。第三,城镇医保和公费医疗所发挥的作用明显高于其他保险形式。本文的基本判断是,国家医保政策在改善中国老人医疗服务利用和减轻老人家庭医疗负担方面确实发挥了良好的积极作用,并且更多惠及了就医必要性更大的老年人群,从资源配置角度看是提高效率的。因此,进一步推进全民基本医疗保障制度的建设不仅是国家惠及全民的医改重任,也是中国医疗卫生应对老龄化挑战的有效选择。     

Managing health care costs in the small business environment

Managed care is bringing down health care costs. But few small business employers find the time to manage their own health, much less that of their employees. Despite time constraints and other factors, small business employers need to embrace managed care. A critical first step is to encourage and support the implementation of important medical management initiatives.     

Can Health Savings Accounts Reduce Health Spending? Evidence from China

Health care costs are high and continue to rise in most major economies, and the health savings account (HSA) is often viewed as an appealing way to contain health care costs because it can potentially solve the moral hazard spending caused by traditional health insurance. This study uses data from the China Household Finance Survey (CHFS) to empirically examine the effectiveness of HSAs in containing medical expenses and reducing moral hazard. The findings show that HSAs that restrict the use of funds may lead enrollees to discount the value and thus spend more on health care. In addition, the positive effect of HSAs on medical expenses is larger for the relatively healthier group, which may suggest that moral hazard exists regarding the use of HSA funds. The empirical estimates of the HSA effect on medical expenses are robust when a set of covariates are controlled, and HSA balances are instrumented using housing savings account balances.     

The relationship between the markets for health insurance and medical malpractice insurance

This article evaluates the interdependence of medical malpractice insurance markets and health insurance markets. Prior research has addressed the performance of these markets, individually, without specifically quantifying the extent to which they are linked. Increasing levels of health insurance losses could increase the scale of potential malpractice claims, boosting medical malpractice losses, or could embody an improvement in medical care quality, which will reduce malpractice losses. Our results for a state panel data set from 2002 to 2009 demonstrate that health insurance losses are negatively related to medical malpractice insurance losses. An additional dollar of health insurance losses is associated with a $0.01–$0.05 reduction in medical malpractice losses. These findings have potentially important implications for assessments of the net cost of health insurance policies.     

The legal challenge to ERISA preemptions

Managed care, once celebrated as a vehicle to halt the increasing cost of health care, has come under increasing fire from patients and health care providers, accused of cutting costs and managing care at the expense of patients. The Employee Retirement Income Security Act of 1974 (ERISA) has been a shield for managed care organizations (MCOs), buffeting them from liability for quality-of-care issues. Lawsuits and legislation are chipping away at the protective shield of ERISA as MCOs find themselves more liable for their decisions and for the care provided by physicians with whom the MCO contracts and provides financial incentives for controlling cost of medical care.     

Unmet need for health care during pregnancy: A French – Romanian comparison

ABSTRACT

Health inequalities emerge from birth, the early neonatal mortality and infant mortality rates being different between countries. These differences may be related to inequalities in use of health care during pregnancy. The aim of this research is to identify and compare the profiles of women who do not follow pregnancy health care recommendations in two European countries with different health systems and indicators: namely France and Romania. However, health care recommendations for pregnant women are free in the two countries. Firstly, unmet need for health care during pregnancy is observed. Secondly, our results reveal that there is a relationship between perinatal health care abandonment and several forms of inequalities (social, informational and psychological). Thirdly, the much higher probability of forgoing perinatal health care for Romanian women could be associated with financial or informational problems which seems counterintuitive because perinatal health care recommendations are free. Free coverage is too insufficient to ensure the efficiency of the perinatal health care system.     

人口老龄化对医疗保险制度的影响——以山西为例

针对人口老龄化对山西医疗保险制度的影响,认为应采取措施增强医疗保障基金积累功能;落实政府公共财政责任,实现医疗保障制度的可持续发展;发展以社区为中心的老年医疗保健服务体系;建立老年保健评估制度。     

中国城镇社会医疗保障改革的理论探索

With its transition to a market-oriented economy, China has gone through significant changes in health care delivery and financing systems in the last three decades. Since 1998, a new public health insurance program for urban employees, called Basic Medical Insurance Program (BMI), has been established. One theme of this reform was to control medical service over-consumption with new cost containment methods. This paper attempts to evaluate the effects of the reformed public health insurance on health care utilization, with in-depth theoretical investigation. We formulate a health care demand model based on the structure of health care delivery and health insurance systems in China. It is assumed in the model that physicians have pure monopoly power in determining patients’ health care utilization. The major inference is that the insurance co-payment mechanism cannot reduce medical service over-utilization effectively without any efforts to control physicians’ behavior. Meanwhile, we use the calibrated simulation to demonstrate our hypothesis in the theoretical model. The main implication is that physicians’ incentive to over utilize medical services for their own benefits is significant and severe in China.      

社会医疗保障改革的福利效应:以中国城镇为例

This paper evaluates Chinese public health insurance reform enforced since 1998 in terms of its welfare effects. We evaluate China health insurance reform since 1998 using the China Health and Nutrition Surveys (CHNS) data with relevant econometric models. The results of empirical studies show that the public health insurance status has significant impact on medical service utilization and expenditure. The reform reduces the positive effect of public health insurance on medical service utilization, meaning the utilization gap is narrowed after the reform. However, the empirical studies find that the medical expenditure growth of the sample individuals in urban China has not been controlled after the Basic Medical Insurance (BMI) program even if a new co-payment is enforced. Two main reasons for this failure might be the rising cost of medical service and physician’s severe moral hazard, while both of them come from no managed care mechanism for medical service providers in China.      

Managed health care: great cost savings with minimal legal risks

Managed care offers great promise for health care cost savings, but it is not without risk. This author suggests how that risk can be minimized.     

A Leak in the Lifeboat: The effect of Medicaid managed care on the vitality of safety-net hospitals

States are increasingly adopting Medicaid managed care in efforts to address budgetary concerns. The intent is that by releasing Medicaid oversight to private organizations, competition will drive down healthcare expenditures so that savings may be passed to the state. Yet there are concerns that this competitive solution to cost savings might compromise safety-net hospitals. Managed care organizations cut costs by restricting the providers that enrollees are allowed to see. If movement in Medicaid patients disrupts safety-net hospitals’ casemix, this could affect their ability to cross-subsidize care. This study estimates the impact of Medicaid managed care on safety-net hospitals by exploiting a Florida pilot program that required Medicaid recipients in five counties to enroll in managed care. The results suggest this mandate led to a small reduction in safety-net hospitals’ average ratio of payment-to-cost. There is also some evidence that the effect on safety-net hospitals was disproportionate. This disproportionality was such that hospitals nearest the margin were pushed the furthest towards the edge.     

我国基本医疗保险制度的激励与监督机制——基于道德风险的分析

逐步在我国建立公平有效的基本医疗保障制度是当前医疗体制改革的首要目标.几年来,尽管我国在这方面取得了一定成绩,但为了防范广泛存在的道德风险,政府的不恰当措施却导致我国在医疗保险体制上出现了诸如门诊负担沉重、报销水平偏低、医疗成本控制过严和医疗保险基金挪用等严重问题.如何解决这些问题是本文研究的关键.我们从分析基本医疗保险的性质出发,集中论述了由共用资源和委托代理关系所引发的道德风险以及政府所面临的两难困境.最后,我们提出了相应的政策建议:政府应在放宽对参保人和医疗机构限制的基础上,通过构建合理的激励与监督机制来健全基本医疗保险体系.     

非理性就医对医保费用管理的挑战及应对策略

目的分析参保患者非理性就医现象,积极探索应对策略,为控制不合理增长的医疗费用提供参考。方法结合我院医保工作中对医保基金正确合理使用的管理及参保患者的就医情况,分析近年来参保患者非理性就医的现象、原因及结果,探索应对策略,总结规范化管理的措施。结果小病大治、大病贵治、无病保养等是非理性就医的主要表现,严重影响医保费用的管理,助推了过度医疗和医疗费用的不合理增长。结论应落实国家医药卫生体制改革,完善配套的医疗保险政策,深化医院医保费用管理,科学控制基本医疗付费总额,控制医疗费用不合理增长,从而保障医保基金的安全使用。     

Employer liability in the managed care setting

Managed care may present legal risks for employers. To avoid potential liability, employers should engage in due diligence and carefully draft plan documents, vendor contracts and employee communications.     

加强农民工医疗保障体系建设的对策建议

农民工为城乡社会的经济发展做出了巨大贡献,而自身则日益"边缘化",其医疗保障问题,日益成为社会各界关注的焦点。建立覆盖全民的分为三个层次城乡一体化医疗保障安全网:第一层次为基本医疗保障;第二层次为补充医疗保障及商业保险;第三层次为医疗救助,可以更好地发挥保障制度在构建和谐社会中的积极作用,最终的目标是构建城镇职工一体化的医疗保险体系。