医保差异化支付促进居民基层就医的效用评价及优化策略

The differentiated health services reimbursement measure is one of the optimization strategies of Chinese government to improve the utilization of primary health services. This measure also is considered to be one of the critical policies of Chinese health care reform. However, the undesirable utilization of primary health services in China is impeding this impact recently. Therefore, the exact effect of this measure on improving primary health service utilization needs to be discovered. And on this basis optimization strategies need to be developed through it..The research on the leverage of health insurance policy is mature, which can bring support to this study. However, currently, the effectiveness of the differentiated health services reimbursement measure on primary health services utilization is still ambiguous. The developed mathematical model can’t evaluate the impact of latent variables on health care utilization and also can’t estimate the interaction among these variables and “Multi-factor and multi-result” relationship. Additionally, there is little in-depth strategy research in the area of improving primary health service utilization in China, and especially a lack of research focus on the intervention effect of differentiated health services reimbursement policy..Therefore, this study will carry outing the comprehensive research, a variety of methods is going to be used to build theoretical and mathematical models suiting to Chinese actual situation, including Gelberg-andersen Behavioral Model, Structural Equation Model, Willingness to Pay Surveys, Cross-sectional Survey, etc. Focus on the differentiated health services reimbursement measure, the current situation and factors associated with primary health service utilization will be discovered. The exact effect of insurance benefit design on improving the primary health service utilization and the major target population of those insurance policies will be detected. Strategies and relative measures, which capable of behavior guidance, will be developed to develop differentiated health services reimbursement measures. In addition, this study would provide theoretical support and strategy advice for policy makers of China’s Health Care Reform.

医保差异化支付是当前我国政府促进居民基层就医的优选策略，但目前政策效果尚不明显。评价医保差异化支付的具体效用，设计切实可行的优化策略以提高基层医疗服务利用，在我国具有显著的理论与实践意义。.当前国内外医保策略杠杆作用研究已较成熟，可为本研究提供参考。但我国医保差异化支付策略促进群众基层就医的效用尚未明晰；医疗服务利用相关影响因素的效用评价仍难以评估感知服务质量等潜在变量的作用，难以实现“多因-多果”关系的影响路径与影响强度估计；鲜有深入的中微观视角的医保策略研究，其中聚焦差异化支付的研究尤为缺乏。.据此，本研究将集成安德森模型、结构方程、意愿支付等方法，聚焦医保差异化支付，明晰其促进群众基层就医的具体效用范围，明确政策发挥作用的重点人群，以最大程度的发挥医保杠杆作用，构建并最终推荐真正具有行为引导效力的优化策略。为提高基层医疗服务利用，完善分级诊疗制度，达成医改预期目标提供科学支撑。

引导社区居民基层就医有序推进分级诊疗是我国医药卫生体制改革的重要内容，未来一段时间内，医保差异化支付政策必仍在我国继续推行。“提高居民基层卫生服务利用”是保障分级诊疗模型建立的基础，我国不容乐观的基层卫生服务利用现状势必将严重阻碍改革效果实现。本研究集成政策制定科学程序、Andersen 模型、结构方程、意愿支付法、横断面调查、专家咨询及深入访谈等方法，构建适合我国国情的基层卫生服务利用理论与数学模型，明确其服务利用现状及影响因素；通过政策研制、可行性评价，构建并最终推荐差异化支付补偿策略及措施。为切实提高基层卫生服务利用，完善分级诊疗制度，达成医改预期目标提供科学依据。.本研究政策文本研究表明目前我国医保差异化支付政策虽推行时间不长，但从样本城市医保差异化支付政策的推行情况来看，整体而言该政策在我国推行的广度与强度均已较大，但从不同地区、不同医保类型与不同等级医院间的差异化水平看仍存有较大差异。亟需从顶层规划出发，制定适宜科学有效的医保差异化支付政策制定策略。.本研究结构方程模型研究结果表明当前政策及医疗环境下，不同强度的医保差异化支付政策并不能有效的引导居民选择基层就医。拟合模型提示在目前医疗服务水平状态和我国医疗政策阶段下，对基层医疗服务利用起到显著性影响的变量有且仅有一项，即需方对于基层医疗服务水平的信任度，居民对基层医疗服务机构的服务能力的不信任是导致医保差异化支付政策实施效力低下的主要因素。目前医疗服务水平状态和我国医疗政策阶段下，对基层医疗服务越为信任的人群更倾向于选择基层就医。另外，生活自理能力较差ADL得分较低的人群，对基层医疗服务水平的信任度水平相对较高，从而更倾向于选择基层就医。.此外，意愿支付研究结果提示当前政策环境下，首先应吸引无配偶、社会支持较好的年轻人群与ADL得分较差的老年人群这两极人群。继而稳固与对基层医疗服务能力较为信任，对医保差异化支付政策比较了解的人群，加大医保差异化支付政策引导力度。未来医疗服务同质化背景下，应加大力度效引导低年龄组敏感人群（15-55岁年龄组）固定并推进基层首诊分级诊疗的良好就医行为的医保方案。.希望本研究能为规范化医保差异化支付政策制定流程与标准，为有条不紊地提高基层卫生服务利用，完善分级诊疗制度提供科学依据。