医保报销比例差距、患者行为选择与医疗费用的关系研究——基于三阶段动态博弈模型的分析

我国初步建立了覆盖全民的医疗保险制度,个人医疗费用自付比例从2005年的52.2%下降到2011年的34.9%,但全社会的医疗总费用和患者平均自付费用的金额却都在大幅度增长; 同时,大医院人满为患和基层医院门可罗雀的现象依然存在. 在这一背景下,本文针对上级医院、下级医院、医保基金以及患者四个参与主体构成的医疗服务体系,构建三阶段动态博弈模型,分析了各参与者的行为,并进行了数值模拟,得出结论: 对上级医院报销比例的上升,会导致去上级医院就医的人数增长,而选择在基层医院就医人数下降,并使得上级医院医疗服务价格、全社会总医疗费用以及患者自付费用总额均会上升; 上下级医院治疗质量的差距也会导致全社会总医疗费用的上涨; 只有合理地利用医疗保险这一政策杠杆来完善分级医疗体系,合理分流患者,并缩小上下级医院的医疗服务质量差距,才能建立更为科学的医疗服务体系,真正减轻患者负担.

Reimbursement gap,patient behavior and medical expenses——A three-stage dynamic game analyses

Universal medical insurance system had been preliminary established in China, individual self-paying medical expense ratio decreased from 52.2% in 2005 to 34.9% in 2011. But the total health expenses of the whole society and the amount of the patients' average self-paying were in substantial increase; At the same time, the phenomenon of big hospitals overwhelmed and grass-roots hospital empty still existed. Under this background, based on the medical service system composed of superior hospitals, subordinate hospital, medical insurance fund, and patients, took the superior and subordinate hospital treatable disease as assumptions, built three-stage dynamic game model, this paper analyzed the behavior of each participant and the numerical simulation, so we got the conclusion: The superior hospital reimbursement ratio rose, which could cause the number of patients in superior hospital increase, and the drop in the population of subordinate hospital, and made the superior hospital medical service price, the whole society total medical expense and patients self-pay total costs rose; Hospital quality gap could also lead to total medical expense rose of the whole society; Only the reasonable use of medical insurance policy could improve classification system, reasonable divergence patients, and reduce the medical service quality gap between the superior and the subordinate hospital, establish a more scientific system of medical service, which really relieved patients' burden.