《保险研究》20260408-《支付杠杆如何激活基层医疗？——来自村卫生室纳入医保定点的证据》（何庆红）

［摘   要］村卫生室作为我国农村三级医疗卫生服务网络的基石,是保障农村居民获得基本医疗服务的“第一道防线”。本文以“村卫生室纳入医保定点”这一关键支付机制改革为准自然实验,基于我国西部九个县2012~2024年的村卫生室年度面板数据,并匹配2021~2023年城乡居民医保100%参保人的就诊数据,构建交错双重差分模型,系统评估医保支付激励对农村居民医疗服务利用行为和分级诊疗格局的影响。研究发现,村卫生室纳入医保定点后,其年度诊疗人次数与总收入显著增加；更为重要的是,该政策有效引导了患者就医流向,参保居民在村卫生室以外的上级医疗机构发生的年度普通门诊次数和门诊费用下降,年度住院次数和住院费用减少,人均年度医疗总支出降低,有效推动形成“小病在基层”的就医格局,显著减轻了居民的医疗经济负担。异质性分析显示,政策影响在公立机构、服务人口较多以及由乡镇卫生院院长管理的村卫生室中更为突出,对农村女性、老年人和低收入群体的影响也更为显著。机制分析进一步揭示,该政策通过优化基层医疗设备配置、降低患者就医的自付费用以及减少可避免住院等途径,促进了医疗资源的合理利用,且未对患者的健康结局产生显著负面影响。本研究结果对于优化基层定点医疗机构资源配置、完善分级诊疗制度、推动基层医疗卫生服务体系高质量发展具有政策启示意义。

［关键词］农村医疗卫生服务体系；支付杠杆；资源配置；分级诊疗

［基金项目］本研究得到中国社会科学院“青启计划”项目(2025QQJH47)和中国社会科学院青年人文社会科学研究中心社会调研项目(2025QNZX021)的支持。

［作者简介］何庆红,中国社会科学院经济研究所助理研究员。

How Does Payment Leverage Activate Primary Healthcare?— Evidences from Integrating Village Clinics into the Medical Insurance System

HE Qing-hong

Abstract：Village clinics serve as the cornerstone of China’s three-tier rural healthcare service network,acting as the “first line of defense” in ensuring rural residents access to basic medical services. This study regards the key payment mechanism reform of “integrating village clinics into the medical insurance system” as the quasi-natural experiment. It analyzes annual panel data from village clinics in nine counties in western China from 2012 to 2024,in conjunction with the medical consultation data of 100% enrollees to the Urban and Rural Resident Basic Medical Insurance between 2021 and 2023. By employing a staggered difference-in-differences model,this study evaluates the impact of medical insurance payment incentives on rural residents’ healthcare utilization behaviors and the tiered diagnosis and treatment system. Results indicate that village clinics witness significant annual increases of  patient visits and total revenue after being included in the medical insurance network. Moreover,the policy effectively redirects patient flows,leading to a reduction in outpatient visits and outpatient costs per insured resident at higher-level medical institutions outside the villages,as well as a decrease of hospital stay and hospitalization costs. This results in decrease in per capita annual total medical expenditure,promoting the treatment of minor illnesses at the primary care level and easing residents’ healthcare financial burden. Heterogeneity analysis reveals that the policy effect is more pronounced in public institutions,those serving larger populations,and those managed by township health center directors. Additionally,the effect is more significant for rural women,the elderly,and low-income groups. Mechanism analysis further reveals that the policy facilitates the rational use of healthcare facilities without significantly impacting patient health outcomes through optimizing primary care facility equipment allocation,reducing patients’ out-of-pocket expenses,and minimizing avoidable hospitalizations. These findings offer valuable policy implications for enhancing resource allocation in designated primary care institutions,refining the tiered diagnosis and treatment system,and advancing the high-quality development of primary healthcare service systems.

Key words：rural healthcare system;payment leverage;resource allocation;tiered diagnosis and treatment