新型农村合作医疗支付方式改革对费用开支影响研究——以浙江省嵊州市为例

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浙江财经学院硕士学位论文

摘要

随着社会经济发展，人民生活水平不断在提高，同时用于医疗卫生方面的支

出也随之不断增加。但是在多种原因的作用下，我国近年来的医疗费用支出呈现

出过快增长的趋势。以往研究表明，医疗保险支付方式的不合理是导致医疗支出

快速增长的一个重要原因。然而，我国大部分地区的新型农村合作医疗制度（以

下简称“新农合”）目前仍然采用按服务项目付费这种支付方式。该支付方式已被

许多专家学者证明是低效率的，容易引发医疗服务供方诱导需求现象，导致医疗

资源的浪费以及医疗费用不合理增长。随着卫生部提出要对新农合支付方式进行

改革，许多地区开展了改革试点工作。

运用博弈论对医方、医保机构、患者这三个主体进行分析的研究有很多，但

大部分还是集中在医疗市场中的逆向选择、道德风险等问题上。而在医疗控费方

面，大部分研究则主要聚焦于医院是否控费与医保机构是否查处的博弈，对于支

付方式改革过程中各主体之间的博弈却鲜有涉及。本文则聚焦于医疗保险支付方

式改革时医方与医保机构之间，医方与患者之间的行为博弈，分析支付方式改革

会对医疗费用的控制产生何种影响。

通过运用博弈理论分别建立医方与保方之间，医方与患者之间在完全信息状

态下的静态博弈模型，得出：当医疗保险支付方式采用预付制时，医方出于自身

利益最大化的考虑，更倾向于不对患者进行诱导需求。因此，预付制在一定程度

上有利于规范医方的诊断行为，遏制医疗费用的不合理增长。通过对嵊州市新农

合参合人员调查问卷的统计分析，发现嵊州市在进行支付方式改革后，参合人员

的年平均就诊费用和门诊平均费用较之改革前均有下降，并且这种差异在统计学

意义上是显著的，这也从实证分析方面验证了博弈模型得出的结论。最后在理论

分析与实证分析的基础上提出相关建议。

全文共分六章。第一章是本文的绪论，主要论述研究的背景，指出目前我国

的新农合支付方式迫切需要改革，同时论述本文研究的理论意义与实际意义。接

着对国内外研究动态进行总结和评述。然后对医疗保险支付方式、医疗费用支付

相关主体等相关概念进行界定。最后论述本文的研究思路，列出研究方法。第二

章对我国新农合支付方式改革的演进历程及现状进行论述。首先对按服务项目付

费所存在的问题及其成因进行分析，接着对我国新农合支付方式改革的政策演变

进行梳理，并对新农合支付方式改革的现状进行论述。第三章则主要运用博弈理

论分别建立医方与医保机构，医方与患者之间在完全信息状态下的静态博弈模型，

浙江财经学院硕士学位论文

分析这三个主体在支付方式改革前后行为的变化，以及由此所产生的对费用支出

的影响。第四章通过对嵊州市新农合参保者的调查问卷以及所获取的其他数据进

行分析，探讨嵊州市新农合支付方式改革对患者医疗费用支出所产生的影响是否

与第三章所得出的结论相一致，并通过问卷了解嵊州市新农合参保群众对医疗保

险支付方式改革的认知状况，以及对新农合的满意程度。第五章分析了英国、德

国、美国这三个国家的医疗保险支付方式，并指出对我国的启示。最后，第六章

在上述分析的基础上得出本文的结论，并提出相关的建议。

关键词：费用支付方式；新型农村合作医疗制度；博弈论；嵊州

浙江财经学院硕士学位论文

III

ABSTRACT

As economy develops, the Chinese citizens’ life quality continues to improve, and

the medical expenses increase as well. Because of multiple reasons, medical expenses in

China showed a tendency of excessive growth recent years. Studies indicated that the

unscientific medical insurance payment system played an important role in inducing the

excessive growth of medical expenses. At present, a payment called FFS(short for “Fee

For Service”), is still under operation in most parts of China. FFS has been proved

unscientific, and will stimulate the doctors to create induced demand. As a result, the

medical expenses will increase excessively.

The Ministry of Health carried out a scheme aiming to reform New Rural

Cooperative Medical Service Payment System. Many districts have drafted regulations.

This thesis consists of six chapters, focuses on the reform of New Rural Cooperative

Medical Service Payment System and its impact on medical expenses. Chapter 1 is

introduction, illustrates the background of this study, points out that the New Rural

Cooperative Medical Service Payment System needs reforms urgently, introduces

former research on this subject, then defines two concepts, lists research methods of this

thesis. Chapter 2 illustrates the evolution of New Rural Cooperative Medical Service

Payment System, analyses its status quo. By applying Game Theory, Chapter 3

constructs two complete information static game models, one between the doctor and

the insurer, the other between the doctor and the patient. Then we will analyze the

changes of their behaviors and consequent impact on medical expenses. Chapter 4

analyzes the questionnaires which were filled in by the insured of New Rural

Cooperative Medical Service in Shengzhou, explores how the medical expenses change,

whether the outcome coincides with the conclusion in Chapter 3. Then, Chapter 5

introduces medical insurance payment systems in UK, Germany, United States, then

compares ShengZhou New Rural Cooperative Medical Service Payment System and the

three above. Finally, a conclusion together with some relevant suggestions is come up in

Chapter 6.

By constructing complete information static game models between the doctor and

the insurer, the doctor and the patient, this dissertation concludes: when pre-payment

system is adopted, in order to maximize his utility, the doctor tend to not create induced

demand. So, to some extent pre-payment system plays a positive role in slowing down

the excessive growth of medical expenses. Analyzing the questionnaires, found that

浙江财经学院硕士学位论文

after the payment system reform, the average medical expenses and the average

outpatient service expenses both decrease. The result coincides with the conclusion

from the game models.

Keywords: Payment system; New Rural Cooperative Medical Service; Game

Theory ; Shengzhou

浙江财经学院硕士学位论文

第一章绪论 ················································································································1

第一节选题背景和研究意义··············································································1

第二节相关概念的界定······················································································2

第三节国内外研究动态及评述·········································································· 4

第四节博弈论概述···························································································· 10

第五节研究思路、方法和主要创新点 ···························································· 12

第二章新农合支付方式改革的演进历程及现状分析············································ 15

第一节按服务项目付费存在的问题及成因分析 ············································ 15

第二节新农合支付方式改革的演进历程和现状 ············································ 22

第三章新农合支付方式改革对费用开支影响的博弈分析···································· 27

第一节医方与医保机构间博弈对费用开支的影响········································· 27

第二节医方与患者间博弈对费用开支的影响 ················································ 29

第四章新农合支付方式改革对费用开支的影响——基于对嵊州市新农合参保者

的问卷分析 ·················································································································· 32

第一节嵊州市新农合支付方式改革情况简介 ················································ 32

第二节调查问卷设计与样本统计描述 ···························································· 33

第三节受访者对新农合支付方式改革的知晓度分析····································· 36

第四节新农合支付方式改革对费用开支影响的统计分析·····························38

第五章国外典型国家医疗保险支付方式的经验借鉴············································ 41

第一节国外医疗保险支付方式的发展趋势 ···················································· 41

第二节典型国家医疗保险支付方式的主要特点 ············································ 42

第三节典型国家医疗保险支付方式对我国的启示········································· 44

第六章研究结论与研究展望·····················································································46

第一节研究结论及建议···················································································· 46

第二节研究展望 ······························································································· 48

参考文献 ······················································································································ 50

附录一新型农村合作医疗支付方式改革调查问卷 ··············································· 53

附录二研究生在读期间发表的学术论文及参加的科研项目································ 55

致谢······························································································································ 56

浙江财经学院硕士学位论文

图表索引

图1 医、保、患三方关系示意图 ·······································································4

图2 论文研究思路示意图················································································· 13

图3 医疗服务市场供需关系图········································································· 17

图4 受访者婚姻状况饼图················································································· 34

图5 受访者年收入分布图················································································· 35

图6 受访者身体状况柱状图·············································································36

表1 非合作博弈的分类及所对应的均衡 ························································· 12

表2 1978-2008 年我国卫生事业费支出··························································· 19

表3 2002-2009 年综合医院收入表··································································· 21

表4 医方与医保机构博弈的标准式表述 ························································· 28

表5 预付制下医方与患者间的博弈 ································································· 30

表6 受访者的年龄和学历················································································· 34

表7 受访者对新农合的了解程度 ····································································· 36

表8 受访者对新农合缴费以及报销比例的看法 ············································· 37

表9 受访者对新农合支付方式改革了解程度 ················································· 38

表10 成对样本检验··························································································· 39

表11 成对样本统计量·······················································································39

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摘要：

浙江财经学院硕士学位论文I摘要随着社会经济发展，人民生活水平不断在提高，同时用于医疗卫生方面的支出也随之不断增加。但是在多种原因的作用下，我国近年来的医疗费用支出呈现出过快增长的趋势。以往研究表明，医疗保险支付方式的不合理是导致医疗支出快速增长的一个重要原因。然而，我国大部分地区的新型农村合作医疗制度（以下简称“新农合”）目前仍然采用按服务项目付费这种支付方式。该支付方式已被许多专家学者证明是低效率的，容易引发医疗服务供方诱导需求现象，导致医疗资源的浪费以及医疗费用不合理增长。随着卫生部提出要对新农合支付方式进行改革，许多地区开展了改革试点工作。运用博弈论对医方、医保机构、患者这三个主体进行分...

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