分级诊疗制度下医保支付体系与医生薪酬制度激励机制研究

Since the implementation of the Hierarchical Diagnosis and Treatment System in our country, the information asymmetry in the medical field has made the medical insurance payment and the physician remuneration system difficult to provide scientific and reasonable incentives to the patients and doctors, which leads to multiple problems that need to be studied and solved in the implementation of the system. For example: the difficulty of two-way referrals, the difficulty for different levels of medical institutions to provide continuous medical services, doctor-patient disputes, unreasonable distribution of medical resources etc.. The inefficiency caused by the existence of these problems causes damage to the welfare of patients and doctors, leading to a reduction in overall welfare of the society. Based on Laffont and Tirole’s incentive theory and regulation theory, this project studies the incentive mechanism of the optimal medical insurance payment system and the physician’s remuneration system. We build models to analyze not only the quantity of medical services and cost control, but also the choice of first visit, referrals between two levels of hospitals, and the communication between doctors and patients. The research of the problems relies on the flexible application and innovation of the relevant theoretical methods in incentive theory, regulation theory, team theory, communication theory and game theory. The expected results of the project will help the government to develop clearer and more feasible health care reform, medical insurance payment policy and physician remuneration system.

我国分级诊疗制度的实施以来，医疗领域中的信息不对称，使得医保支付和医生薪酬制度仍然未能给患者和医生提供科学合理的激励，导致制度的实施中显现出诸多有待研究和解决的问题。例如：双向转诊均困难，各级医疗机构之间不能提供连续性的医疗服务，医患纠纷严重，医疗资源分配不合理等。这些问题的存在造成的无效率对患者和医生的福利造成损害，导致社会整体福利的降低。本项目基于Laffont和Tirole激励理论和新规制理论的视角，在对医疗服务数量及成本控制研究的基础上，对首诊选择、两级医院间转诊选择，以及医患沟通共同决策进行建模，系统地研究分级诊疗制度下最优医保支付制度与医生薪酬制度的激励机制。问题的研究有赖于对激励理论、规制理论、小组理论、沟通理论和博弈论等相关理论工具的灵活运用和创新。本项目研究的预期结果有助于政府制定更清晰和可操作的医改和医疗保险体系及医生薪酬制度。

本项目利用博弈论和契约理论为工具，研究了医保支付体系和医生薪酬制度的激励机制如何促进分级诊疗更有效地实施。具体而言，第一，需方价格差异化和供方医联体联合运用比单一政策更有优势，联合并精确设计两项政策有助于推动分级诊疗实现社会最优的首诊分配。第二，日间手术是推动分级诊疗的一种重要诊疗方式。本项目基于东部战区总医院日间手术管理中心的实践经验，探索日间手术的分级诊疗双向转诊模式。可行的道路是，通过分级诊疗让社区或二级医院参与进来，协助三甲医院完成日间手术患者筛选和术后的康复工作，三甲医院通过成立医疗联合体及帮带合作模式确立双方合作基础。第三，道德风险与逆向选择同时存在时，最优医生薪酬制度的激励机制是按人头付费、按项目付费和按绩效付费的混合设计使用。按绩效付费可以为基层全科医生提供激励，激发医生的努力程度，提高基层医疗服务质量，同时，按项目付费也为医疗服务量和医疗质量提供了一定的保证，在一定程度上，为分级诊疗以及基层首诊逐步地更有效地实施提供保障。第四，本项目采用政府-医生-投保人（患者）三方合约框架研究医患共策下患者医保支付和医生薪酬支付的整合制度，研究发现，如果医生的努力程度对患者的健康恢复很重要，那政府医保部门应该依靠给患者提供激励。本项目的研究成果为国家制定更清晰和可操作的医疗保险和医生薪酬制度、促进分级诊疗制度更有效地实施提供了理论依据。