我国社会医疗保险与医疗服务提供方互动的研究

发布时间：2018-06-29 14:55

本文选题：社会医疗保险 + 医疗服务提供方　；参考：《华中科技大学》2013年博士论文

【摘要】：研究目的：随着全民医保时代的到来及我国新医改的不断深入，社会医疗保险与医疗服务提供方建立良性互动机制对协调相关利益方形成合力，推动中国医药卫生体制改革具有重大意义。然而，当前我国医疗保险方与医疗服务提供方的良性互动不足。本研究旨在分析社会医疗保险与医疗服务提供方的互动关系，探索双方互动的影响因素及激励约束机制，为促进社会医疗保险与医疗服务提供方的良性互动提供政策建议。研究方法： 1.文献研究法通过系统搜集、整理、分析和归纳文献，重点掌握国内外对社会医疗保险与医疗服务提供方互动的研究现状，拟定本研究的思路。 2.访谈法通过对医疗保险机构的管理人员、医疗机构的管理者及医务人员、有关专家进行定性访谈和咨询，修正研究思路和方法，并为调查问卷设计提供基础和铺垫。 3.问卷调查法按照中国东部、中部和西部地区划分，选取深圳、上海、湖北、江西、四川、重庆作为调查点，总共发放医疗机构人员问卷480份，发放医保机构人员问卷60份。对所搜集到的数据用SPSS13.0进行统计和分析，包括：①使用描述性统计分析对医疗保险机构和医疗机构的互动现状和特征进行分析；②运用因子分析法探索医疗保险机构和医疗机构互动的影响因素。 4.案例研究法通过搜集典型案例，对医疗保险改革与医疗卫生改革的相互作用、新型农村合作医疗制度促进医疗服务提供体系的发展、新型农村合作医疗支付方式改革、医院适应医疗保险转变发展方式等进行深入的个案分析。研究结果： 1.医疗保险与医疗服务提供方的互动有两种表现形式：良性互动与非良性互动。社会医疗保险与医疗服务提供方互动存在的问题有：医疗保险费用控制的压力较大；社会资本比较薄弱；双方之间存在非合作博弈的关系；交易成本较高。 2.社会医疗保险与医疗服务提供方互动的影响因素为社会资本、社会行为体力量、交易成本、违约控制、价值取向、协商频率。不同地域在交易成本、价值取向、社会资本和违约控制上存在显著差异（p0.05）；不同级别医疗机构在交易成本上存在显著差异（p0.05）；不同职称人员在交易成本因子、价值取向因子上存在显著差异（p0.05）；医疗机构人员的性别与学历对医疗保险方与医疗服务提供方的互动不构成任何影响。 3.社会医疗保险与医疗服务提供方互动的激励约束机制体系包括谈判机制、医保付费机制、考核评价机制、信息披露机制和外部监督机制。研究结论： 1.医疗保险改革要与医疗卫生改革同步推进，促进医疗保险方与医疗服务提供方的良性互动，卫生改革才能成功。 2.应推进以下改革措施：推进医疗保险法律法规的建设；通过医疗保险作用推动医疗服务提供体系的变革；建立医保基金监测及分析体系；探索医保付费按绩效支付；塑造健康的社会合作文化。研究创新之处： 1.运用多学科结合的研究视角，综合运用社会学、经济学、管理学等学科的理论与方法，深入分析社会医疗保险与医疗服务提供方互动的本质、原理、机制、内容和影响因素等，建立了双方互动关系的理论分析框架，拓宽了医疗保险研究的研究视野。 2.从定性和定量两个方面探索社会医疗保险与医疗服务提供方互动的影响因素，结合案例研究，阐释双方互动的实践表现，为在卫生改革中重视社会医疗保险与医疗服务提供方的互动提供循证支持。 3.构建了促进社会医疗保险与医疗服务提供方良性互动的激励约束机制，，对卫生决策及管理实践具有启示作用。研究不足之处: 1.医保机构人员问卷调查的样本量比较小。 2.未能对社会医疗保险与医疗服务提供方互动的效果评估做深入研究。
[Abstract]:The purpose of the study is:
With the arrival of the age of medical insurance for the whole people and the deepening of the new medical reform in China, the establishment of a benign interaction mechanism between the social medical insurance and the medical service providers is of great significance to coordinate the relevant stakeholders and promote the reform of the Chinese medical health system. However, the healthy interaction between the medical insurance party and the medical service provider in China is at present. The purpose of this study is to analyze the interaction between the social medical insurance and the provider of medical services, to explore the influencing factors and incentive and constraint mechanism of the interaction between the two parties, and to provide policy suggestions for the promotion of the benign interaction between the social medical insurance and the medical service provider.
Research methods:
1. literature research method
Through systematic collection, collation, analysis and induction of literature, the research status of the interaction between social medical insurance and medical service providers at home and abroad is focused on, and the ideas of this study are drawn up.
2. interview method
Through the qualitative interview and consultation to the administrators of medical insurance institutions, the managers and medical staff of the medical institutions, the relevant experts, the research ideas and methods are corrected, and the basis and paving for the design of the questionnaire are provided.
3. questionnaire survey method
According to the eastern, central and western regions of China, Shenzhen, Shanghai, Hubei, Jiangxi, Sichuan and Chongqing were selected as the survey points. A total of 480 questionnaires were issued and 60 medical insurance agencies were issued. Statistics and analysis were made on the data collected by SPSS13.0, including: (1) the use of descriptive statistical analysis to medical insurance The present situation and characteristics of interaction between insurance institutions and medical institutions are analyzed. Secondly, factor analysis is used to explore the influencing factors of interaction between medical insurance institutions and medical institutions.
4. case study
Through collecting typical cases, the interaction between medical insurance reform and medical and health reform, the development of new rural cooperative medical system to promote medical service supply system, the reform of new rural cooperative medical service payment mode, and hospital adaptation to medical insurance change and development mode are carried out in depth case analysis.
The results of the study:
1. the interaction between medical insurance and the provider of medical service has two forms: benign interaction and non benign interaction. The problems existing in the interaction of social medical insurance and medical service provider are: the pressure of the medical insurance cost control is larger; the social capital is weak; the relationship between the two sides in the non cooperative game; the transaction cost. Higher.
2. the factors affecting the interaction between social medical insurance and medical service providers are social capital, social behavior strength, transaction cost, default control, value orientation, negotiation frequency. Different regions have significant differences in transaction cost, value orientation, social capital and default control (P0.05); different levels of medical institutions exist in transaction costs. There are significant differences (P0.05); there is a significant difference in the transaction cost factor and the value orientation factor (P0.05) for different professional titles. The gender and educational background of the medical institutions do not have any effect on the interaction between the medical insurance party and the provider of medical service.
3. the incentive and constraint mechanism of the interaction between social medical insurance and the provider of medical services includes negotiation mechanism, medical insurance payment mechanism, assessment and evaluation mechanism, information disclosure mechanism and external supervision mechanism.
The conclusions are as follows:
1., the reform of medical insurance should be synchronized with the reform of medical and health care, so as to promote the positive interaction between the medical insurance providers and the providers of medical services, so that the health reform can be successful.
2. we should promote the following reform measures: promote the construction of medical insurance laws and regulations, promote the reform of medical service delivery system through the role of medical insurance, establish the monitoring and analysis system of medical insurance fund, explore the payment of medical insurance pay according to the performance, and shape a healthy social cooperation culture.
Research Innovation:
1. using the theory and method of sociology, economics, management and other disciplines, it analyzes the essence, principle, mechanism, content and influence factors of the interaction between social medical insurance and medical service providers, and sets up the theoretical framework of the interaction relationship between the two sides, and broadens the research research on medical insurance. Look into the field of vision.
2. explore the influence factors of the interaction between the social medical insurance and the medical service provider from the qualitative and quantitative two aspects, and combine the case study to explain the practical performance of the interaction between the two sides, and provide evidence-based support for the interaction between the social medical insurance and the provider of medical service in the health reform.
3., an incentive and restraint mechanism to promote the benign interaction between social medical insurance providers and medical service providers has been constructed, which will enlighten the practice of health policy-making and management.
The shortcomings of the study are:
1. the sample size of medical insurance personnel questionnaire is relatively small.
2. failed to make an in-depth study of the effectiveness evaluation of interaction between social health insurance providers and medical providers.
【学位授予单位】：华中科技大学
【学位级别】：博士
【学位授予年份】：2013
【分类号】：F842.684

【参考文献】