研究背景及目的：2020年，中共中央国务院在《深化医疗保障制度改革的意见》中提出建立管用高效的医保支付机制，即病组病种分值付费（DRG/DIP）和“结余留用、超支自负”的“成本约束-剩余索取”激励机制。本文研究该医保支付机制及医保与定点医疗机构的协同治理，最终对医保基金支出和结余的影响；通过异质性分析探究医保支付方式改革在不同城市特征、改革方式下政策效果差异；总结医保支付方式改革成效和问题，为后期深化医保支付方式改革提供依据。研究方法：为实现时间长度和周期的有效性，本文采集中国230个城市2016-2021年的医保基金决算数据，运用多时点双重差分方法，分析实施医保支付方式改革（以DRG/DIP为主）对医保基金支出的影响及其异质性效果；在实证结基础上结合质性分析，基于协同治理理论中的SFIC框架，建立医保支付方式改革下“医保-医疗”协同治理模型，对改革中“医保-医疗”协同效果进行分析和总结。研究结果：1、医保支付方式改革有效降低了城镇职工医保人均支出，并显著提高城镇职工医保基金结余率，在经过检验后结果依然稳健。同时，医保支付方式改革在降低城乡居民医保人均支出、支出增速和提升医保结余率方面并未出现显著效果；2、异质性分析发现，职工参保人数占比低、经济发展水平高及财政支持力度大的城市，医保支付方式改革效果更为显著；采取病组分值付费（DRG）城市相对于病种分值付费（DIP）城市，及前期分散试点城市（以DRG为主）相对于后期国家集中试点城市，医保支付方式改革效果更为显著；3、中国医保支付方式改革的机制效应具有波动性，且与目标结果存在差距，分析其主要原因是“医保-医疗”间协同性不足。具体而言，存在“协作动机缺乏”、“领导者引导力不足”，“制度设计缺位”以及“协同过程要素缺失”等问题，导致“医保-医疗”协同机制效果减弱，弱化了医保支付方式改革效力。研究贡献：1、本文数据时长6年，有利于把握医保支付改革成效，国内相关研究时长较短；2、探索和尝试了医保病组病种分值付费改革的定量和定性评估方法；3、从协同治理视角总结医保支付改革的成效，并发现协同不足及其相关问题。建议与展望：1、建立相关利益人有效沟通机制；2、动态调整医保支付改革政策，提高政策科学性；3、完善医保支付改革的激励机制和两定机构绩效评估机制；4、进一步加强两定机构、医生药师行为监督及医保基金监管。
Background and objectives: In 2020, the CPC Central Committee and the State Council proposed in the Opinions on Deepening the Reform of the Medical Security System the establishment of an effective and efficient medical insurance payment mechanism, namely, the Disease Group Divided Invalue Payment (DRG/DIP) and the Cost Constraints - Residual Claims incentive mechanism, which is to “keep the balance and use it, and be responsible for the cost of overspending”. This paper investigates the health insurance payment mechanism and the incentive mechanism of “cost-constraint-surplus-requirement”. This paper studies the impact of this health insurance payment mechanism and the synergistic governance of health insurance and designated medical institutions on the expenditure and balance of the health insurance fund; explores the differences in the policy effects of the health insurance payment reform in different cities with different characteristics and reform modes through heterogeneity analysis; and summarizes the effectiveness of the reform of the health insurance payment mode and the problems, so as to provide a basis for the deepening of the reform of the health insurance payment mode in the later stage.Methods: In order to achieve the validity of the time length and period, this paper collects the final health insurance fund data of 230 Chinese cities from 2016 to 2021, and applies a multi-temporal double-difference methodology to analyze the impact of the implementation of health insurance payment reforms (mainly DRG/DIP) on the expenditure of the health insurance fund and its heterogeneous effects;On the basis of empirical findings and qualitative analysis, based on the SFIC framework of collaborative governance theory, we establish a collaborative governance model of health insurance and health care under the reform of health insurance payment method, and analyze and summarize the collaborative effect of health insurance and health care in the reform.Results: 1. The reform of the health insurance payment method has effectively reduced the per capita expenditure of urban workers‘ health insurance and significantly increased the balance rate of the urban workers‘ health insurance fund, and the results remain robust after testing. At the same time, the reform of the health insurance payment method has not shown any significant effect in reducing the per capita expenditure on health insurance for urban and rural residents, the growth rate of expenditure and the increase in the balance rate of health insurance;2. Heterogeneity analysis found that the effect of health insurance payment reform is more significant in cities with a high proportion of employees, a high level of economic development and strong financial support; the effect of health insurance payment reform is more significant in cities adopting the Disease Group Value-based Payment (DRG) versus those adopting the Disease Itemized Value-based Payment (DIP) and in cities with decentralized pilots in the early stage (with DRG as the mainstay) versus cities with centralized pilots in the later stage of the process. (b) The effect of health insurance payment method reform is more significant in DRG cities than in DIP cities, and in decentralized pilot cities (mainly DRG) than in centralized pilot cities;3. The main reason for the fluctuating effect of the mechanism of China‘s health insurance payment reform and the gap between it and the target results is the lack of synergy between health insurance and health care. Specifically, there are problems such as "lack of motivation for collaboration", "insufficient guidance from leaders", "lack of system design" and "lack of elements of the collaborative process". "This has led to a weakening of the effectiveness of the health insurance-health care synergy mechanism and weakened the effectiveness of the health insurance payment reform.contribution: 1, the data in this paper is 6 years long, is conducive to grasp the effectiveness of health insurance payment reform, domestic related research is shorter;2. Quantitative and qualitative assessment methods for the reform of value-based payment for illnesses in health insurance groups have been explored and attempted;3. Summarize the effectiveness of the health insurance payment reform from the perspective of collaborative governance, and identify the lack of collaboration and its related problems.Recommendations and prospects：1. Establishment of an effective communication mechanism for relevant stakeholders;2. Dynamically adjust the health insurance payment reform policy and improve the scientific nature of the policy;3. Improve the incentive mechanism for health insurance payment reform and the performance evaluation mechanism of the two organizations;4. Further strengthening the supervision of the behavior of the two organizations, doctors and pharmacists and the supervision of the health insurance fund.
