Game analysis on hospital outpatient payment methods of Chinese basic health insurance based on principle-agent theory
10.3760/cma.j.cn111325-20221114-00969
- VernacularTitle:基于委托代理理论的我国医院门诊医保支付方式博弈分析
- Author:
Qiong WU
1
;
Yuehui LIU
;
Lihua LIU
;
Xiaojing MA
Author Information
1. 中国医学科学院医学信息研究所，北京 100020
- Keywords:
Basic medical insurance;
Outpatient payment method;
Medical insurance supervision;
Principal-agent theory;
Game theory
- From:
Chinese Journal of Hospital Administration
2023;39(2):87-92
- CountryChina
- Language:Chinese
-
Abstract:
As the major means of outpatient payment for basic medical insurance (the insurance for short) relies on fee-for-service, it tends to encourage unreasonable growth of medical expenses. Based on the principal-agent theory, this paper analyzed the principal-agent relationship between the insurance handling agencies and the hospitals designated by the insurance, and constructed a benefit game model of outpatient payment methods and the supporting supervision game model. This practice aims to explore the optimal and balanced benefit of the insurance payment methods and supporting supervision mechanism, and provide decision support for promoting the reform of medical insurance outpatient payment in China. The analysis results of the benefit game model of payment methods showed that a system mixing the post-payment and pre-payment could optimize and maximize the total benefits and interests of all the stakeholders within the system. Specifically, the practice recommended was a mixed payment integrating ambulatory-payment-classification, fee-for-service and global-budget-payment. The analysis of the supporting regulatory game model found that the factors that must be considered to ensure the expected utility of the above mixed payment mode as follows: the gap between the unreasonable income obtained by the hospital by out-of-control charging and the reward obtained by under-control charging, the size of the penalty after the unreasonable income of the hospital was discovered, the size of the regulatory cost and the loss of benefits of the government and the insured group. It is suggested to adopt the mixed payment method mainly based on the ambulatory-payment-classification supported by fee-for-service and global-budget. At the same time, medical insurance agencies can improve their supervision mechanism from such aspects as perfecting penalties, reducing supervision costs, leveraging government administrative power and advocating public supervision.
