An analysis on formation mechanism and balance affiliation between health insurance payment standard and market price / 中国卫生政策研究

ABSTRACT

At present,because market price survey and health insurance payment standard adjustment mechanism in china is incomplete,health insurance payment standard can not be completely equivalent to the actual market price of drugs. This paper analyzed and summarized the main factors affecting the balance and formation mechanisms under differ-ent medical insurance payment standard policies. It is found that the balance formation mechanism depends not only on the reimbursement ratio of drugs,but also on the development pattern of the payment standard and on the source of the refer-ence price system selected. On the issue of the ownership of the balance,from the specific practices of pilot cities such as Chongqing and Shaoxing,it can be seen that the merits and demerits still exist to the medical institutions for internal de-velopment models or re-allocated by the government agencies'performance-based. Compared with the simple balance reten-tion model,the redistribution model can enhance the service of medical institutions by regulating their behavior. However, medical institutions may provide false data to get more balance in the redistribution model,and game theory was used to reduce the policy risk of misreporting the private balance of data from medical institutions,and the analysis of strategic choices of medical institutions and supervisory departments Finally,"three-step"policy proposal was proposed on the issue of balance attribution. In the short term,the balance should be given to the medical institutions to increase their bargaining motivation. At the same time,the performance appraisal and supervision methods should be explored to enhance the feasi-bility of redistribution model. In the long run,the balance should be eliminated gradually through the improvement of mar-ket price survey and medical insurance payment standard adjustment mechanism.