医疗保险预付费方式控制医疗费用的机制研究

医疗保险以控制医疗费用为重要职能,以预付费方式为主要手段。医疗保险预付费方式实际上是一种“定额”付费方式,以“超支自负和结余归己”的固定结算制度为控费机制。目前,部分地区的医保机构对医疗机构采取“超支分担、结余奖励”的弹性结算制度,部分地区对医疗机构采取“超支自负、结余归人”或“超支分担、结余归己”的半固定半弹性结算制度。这些结算制度不是“定额”付费方式,而且“限额”付费方式,原本是为了既控制医疗费用又防范医疗风险,结果是既不能控制医疗费用又不能防范医疗风险。

Mechanism of Prepaid Method of Medical Insurance in Controlling Medical Expense

To control the medical expenditure is an important function of medical insurance. Prepaid method is main way to control the medical expenses. Medical insurance prepaid is actually a "quota" payment, "overruns in vain and surplus for yourself" is the main mechanism of prepaid method control expenses. At present, health insurance institutions adopt flexible payment or semi-fixed and semi-flexible payment in some areas. The payment method is not a "quota" payment but a "limit" payment, with a view to not only control the medical expenses but also prevent medical risk, however it can not control medical expenses and can not prevent medical risks ultimately.