《保险研究》20220207-《社会治理与医保支付改革：理论分析与国际经验》（顾昕、惠文、沈永东）

［摘   要］医保支付改革是全球性医疗保险改革的核心，在中国医药卫生体制改革中具有战略意义。在社会医疗保险主导的体系中，医保支付改革的实质是行政力量通过行政机制的引领作用，在医保支付者和医疗服务者之间建立公共契约制度，运用市场机制，重构医疗服务供方的激励结构，以期提升效率，遏制供方诱导需求。由于医保支付方式呈现多样性和复杂性，公共契约制度化依赖于社群机制的运作，包括医学会、医师协会和医院管理协会等在内的医界社会组织为新医保支付方式的选择及其细节游戏规则的制定提供专业性、技术性支撑，对于医保支付改革的成功推进，是不可或缺的。唯有多方利益相关者协作互动，多种治理机制互补嵌合，政府在此过程中扮演元治理者的角色，达成社会治理之境，才能推动医保支付改革砥砺前行。

［关键词］医保支付改革；社会治理；公共契约；协作/互动治理；社会组织；社群机制

［基金项目］本文系浙江省哲学社会科学优势学科重大资助课题“走向去碎片化和去行政化:医疗保障局与新时代中国医疗事业的公共治理创新”(19YSXK02ZD)、浙江省哲学社会科学规划课题“从政府行政定价到多方谈判定价:价格管制改革与医药产业的发展”(19YSXK02ZD-3)和国家自然科学基金重点招标项目“提升基层医疗卫生服务能力研究”(71734005)的阶段性成果。

［作者简介］顾昕，浙江大学社会治理研究院首席专家、公共治理与民生保障研究中心研究员、公共管理学院教授；惠文，浙江大学公共管理学院博士生，浙江财经大学东方学院讲师；沈永东(通讯作者)，浙江大学公共管理学院长聘副教授，社会治理研究院副院长。

Social Governance and the Reform on Medical Insurance Payment:An Theoretical Analysis and International Experiences

GU Xin,HUI Wen,SHEN Yong-dong

Abstract：The reform on the medical insurance payment is at the core of the reform on medical insurance globally,and has a strategic significance in China′s medical and health system reform.In the system led by social medical insurance,the payment reform is,in essence,for the administrative force to establish a public contract system between the medical insurance payer and the medical service provider through the steering role of the administrative mechanism,mobilize the market mechanism,and restructure the incentive mix for the medical service provider,in order to raise efficiency and curb supply-side induced demands.Due to the great variety and complexity of the forms of payment for medical insurance,the formation of the public contract system depends on the operation of the social group mechanism,and the specialized and technical support of social organizations in the medical field,such as medical associations,associations of physicians,and hospital administration institutions,etc.,to establish detailed game rules for the new payment options.These supports are inseparable for the successful progress of the payment reform.Moreover,the cooperation among all stakeholders,the complementation of various governance mechanisms,and the governance  role played by the government to reach the social governance level,these factors need to work together to propel the medical insurance payment reform to forge ahead.

Key words：medical insurance payment reform;social governance;public contract;cooperative/interactive governance;social organizations;social group mechanism