基于“价值”导向的支付方式对医联体激励约束机制和政策优化研究

This study used the behavioral economics, experimental economics and system dynamics, integrated the empirical research, experiment research and system simulation, combined the qualitative, quantitative methods and the view of value-based healthcare, combined the external payment methods and internal interest distribution way of medical alliance, specified the economic incentive and restrictive mechanism elements of medical alliance with different payment methods, established the quantitative relationship between the "expect spreads - decision making effort - actual decision making behavior", which based on empirical research and the expectation theory. In this study, we analyzed the core and non-core medical institutions managers' decision making behavior effort and results under different combination of internal and external payments by experimental economics, and established the simulation model between "payment methods - expect spreads - decision making efforts - actual decision making behavior - value targets", determined the key link of economic incentive and restrictive mechanism through the system dynamics sensitivity analysis, established the medical alliance of shared interests by optimizing the economic incentive and restrictive mechanism, promoted the medical alliance of shared service and management, to provide the theory and practice basis of improving payment methods and constructing health service system based on the value, through the optimization of economic incentive constraint mechanism of medical alliance to promote to establish the medical benefit community, service community and management community, provided the theory and practice basis to improve the payment method and construct health service system based on the value. This study provides a new perspective of value-based healthcare for the effect of payment method on the economic incentive and restrictive mechanism of medical alliance, and expands the field of behavioral economics, experimental economics and system dynamics.

本研究综合运用行为经济学、实验经济学和系统动力学，将实证研究、实验研究和系统仿真相结合，定性与定量相结合，以价值为目标导向，把医联体外部支付方式和内部利益分配机制有机结合，明确支付方式对医联体激励约束机制要素框架，在实证研究基础上通过期望理论建立“期望收益差—决策努力程度—实际决策行为”之间的定量关系。通过实验经济学分析内外部支付方式不同组合下，医联体核心和非核心医疗机构管理者的决策行为努力程度和决策结果，并通过建立“支付方式—期望收益差—决策努力程度—实际决策行为—价值目标”之间的仿真模型，运用系统动力学的敏感性分析确定激励约束关键环节，通过优化经济激励约束机制促进建立医联体利益共同体，实现服务共同体和管理共同体，为完善支付方式，建设基于价值的医疗服务体系提供理论和实践依据。本研究为评估支付方式对医联体激励约束效果提供了价值导向新视角，拓展了行为经济学、实验经济学和系统动力学运用领域。

本研究以“价值”为导向，行为经济学和传统经济学结合，医联体外部支付方式和内部利益分配机制结合，选取深圳市两个城市紧密型医联体、福建三明尤溪、湖北省共四个县域医共体进行典型案例研究，结合博弈论实证分析内外部支付方式不同组合下医联体管理者、医生决策行为和绩效结果，提出优化策略，促进建设价值医疗服务体系，实现三医联动。.结果：城市医联体在财政投入、医保支付、薪酬改革等方面组合经济激励，基层卫生服务利用、慢病管理、双向转诊均有所提升。对医生问卷通过结构方程分析外部经济激励对医联体绩效的影响机制，医院内部激励机制对医生整合服务行为影响最强（标准化路径系数为0.542，P＜0.001），超过了医生认知和管理者态度。转诊和资源下沉动力随激励标准增加而增加。同时大多数医生（86%）选择与常规工资分开发放、激励立即到账的激励方式。.紧密型县域医共体“双打包”激励机制改革效果显著，尤溪县基层医疗卫生机构诊疗人次占比从50.8%提高至69.2%，高血压、糖尿病、重性精神障碍规范管理率上升，但年薪工分制中工作量工分占比过高仍会诱导医生冲点行为。黄州与潜江医共体监管与医保支付协同提升了基层诊疗人次占比（P=0.000）。间断时间序列分析显示当阳医共体按人头总额预付后，基层医疗卫生机构诊疗人次占比上升，向下转诊患者比例提高，但基层医疗卫生机构医保基金占比和医务人员人均收入占比降幅较大。.结论：医保支付激励是促进医联体整合的核心政策工具，关键环节是总额预付结合余额分担激励成员合作，影响机制路径为医联体外部经济激励—内部绩效分配—医生行为—医联体绩效，经济激励形式也会影响激励效果。总额预付同样能促进非紧密型医共体整合，但存在机构间利益分配不合理。建议以价值为目标通过医共体总额预付发挥外部支付激励约束机制，创新整合型政府财政投入，同时完善绩效考核体系，建立科学的医联体利益分配机制，加强内部薪酬制度联动改革。