【作者】 黄凤；

【导师】 杨东亮；

【作者基本信息】 华中科技大学 ， 社会医学与卫生事业管理， 2013， 博士

【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（p<0.05）；不同级别医疗机构在交易成本上存在显著差异（p<0.05）；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（p<0.05）；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。更多还原

【Abstract】 Purpose：With the coming of universal health insurance and the deepening of the new health reform, it isof great significance to make positive interactions between social health insurance and health careprovider to push healthcare system reform in China. However, there are many problems in thehealth insurance system. This research aims to explore the relationship between social healthinsurance and health care provider, the influencing factors, the incentive and restraint mechanism oftheir interaction and provide the policy recommendations to promote positive interaction betweensocial health insurance and health care provider.Methods：1. Literature researchThe current situation of studies both at home and abroad was hold and the research idea wasdetermined by collecting, organizing, analyzing and summarizing the literatures,.2. Interviewing methodThe research idea and methodology was revised and it provided the foundation for questionnairedesign by qualitative interviews and consultation among the insurers, managers of medicalinstitutions, medical staff and experts.3. Questionnaire surveyThe survey areas including Shenzhen, Shanghai, Hubei, Jiangxi, Sichuan and Chongqing wereselected according to geographic region of the East, the Central and the West in China. Totally480medical staff questionnaires and60insurers questionnaires were sent out. The data were analyzedby SPSS13.0, specific methods include:①To analyze the current situation and characteristic of theinteraction between the health insurer and health care provider by descriptive statistic;②Toexplore the influencing factors of interaction by factor analysis.4. Case studySome typical case were collected and studied, such as the interaction between health insurance reform and healthcare reform, New Rural Cooperative Medical Scheme how to promote thedevelopment of health care system, payment method reform of New Rural Cooperative MedicalScheme and hospital how to adapt to the transformation of development pattern of health insurancesystem.Results：1. There are two forms of performance for the interaction between health insurance and healthcare providers: positive interaction and non-positive interaction. The problems existing in theinteractions between social health insurance and health care provider are: the high pressure of healthinsurance cost control, the weakness of social capital, the non-cooperation relationship between thesocial health insurance and health care provider and the high transaction cost.2. The influencing factors of the interaction between social health insurance and health careprovider are social capital, social actor power, transaction cost, default control, value orientationand negotiation frequency. There are significant differences between transaction cost, valueorientation, social capital and default control in different regions (p<0.05). There are significantdifferences between transaction cost in different level medical institutions (p<0.05). There aresignificant differences between transaction cost factor and value orientation factor in the personwith different job title (p<0.05). Gender and education background have no effect to the interactionsbetween social health insurance and health care provider.3. The system of incentive and restraint mechanism of interactions between social healthinsurance and health care provider includes negotiation mechanism, health insurance paymentmechanism, assessment and evaluation mechanism, information disclosure mechanism and externalsupervision mechanism.Conclusions:1.The health insurance reform should be pushed forward synchronously with the health carereform, promoting the positive interaction between health insurance and health care provider, thenthe health care reform can finally be succeed.2.The following reform measures should be promoted: promoting the laws and regulationconstruction of health insurance; pushing forward the revolution of medical service system throughthe effect of health insurance; establishing the monitoring and analyzing system of health insurance fund; exploring the payment method of ‘pay for performance’; shaping a healthy socialcooperative culture.Innovations：1. A theoretical analytical framework of the interaction is established, and it offers amethodological guidance for the construction of the positive interaction between social healthinsurance and health care provider by applying a multidisciplinary perspective and using thetheories and methods of sociology, economics and management to analyze the natures, principles,mechanisms and contents of the interactions.2. By exploring the influencing factors of the interaction between social health insurance andhealth care provider from the qualitative and quantitative aspects and combined with the casesstudies, the practice performance of the interaction is interpreted to provide evidence for valuing theinteraction between social health insurance and health care provider during the health reform.3. It plays a role of enlightenment for the health decision and health management practice byestablishing an incentive and restraint mechanism to promote the positive interaction between socialhealth insurance and health care provider.Limitations：1. The questionnaires survey of insurers is a small sample size.2. There is no in-depth study on interaction evaluation between social health insurance andhealth care provider.更多还原