Research On Negotiation Mechanism Of Social Health Insurance In China

ObjectiveThrough depth analysis of principal subject in social health insurance field on the main game mode, the author tries to further clarify the essence mean of negotiation mechanisms on social health insurance. Subsequently, the article formats the basic framework of negotiation mechanism on social health insurance, and looks for the implementation path with the national social health insurance negotiation. With construction of negotiation mechanism, it will promote full medical insurance for more efficient use of funds and coordination of health care stakeholders to play together. On the whole it has important theoretical and practical significance on the sides about the development of China's health reform and the medical services market.MethodsThrough quantitative and semi-quantitative analysis for the literature of social health insurance negotiations by bibliometric methods and content analysis, the author collected systematically the core elements of the social health insurance negotiations mechanism in the future. With incomplete information principal-agent analysis between hospitals and health insurers, negotiation theory model building was complete. Some questionnaire surveys and in-depth interviews for knowledgeable informants were carried out to understand the current situation, problems, influential factors of negotiations and bargaining with both sides. Data analysis:Descriptive analysis including measurement data of the mean, standard deviation. By advanced SWOT analysis accurate analysis and clear development strategy was made for the construction and development of health care bargaining internal and external environment.Using time series analysis method to track the empirical research reform of the hospital after payment of medical acts. Data analysis were mainly by softwares such Eviews5, Super Decisions, SPSS 12.0 and so on.Results1. Bibliometric analysis of health insurance negotiation mechanisms:The thesis retrieves 42 standard literatures of health insurance negotiation mechanisms in the past 5 years, through the methods of quantitative analysis and content analysis. The six core elements of negotiation mechanisms were defined preliminarily by comprehensive health insurance document information, including the mode, the main bodies, content, procedures of negotiations and related supporting mechanisms.2. Related theory:Some theories were selected to described such as negotiation theory, public administration theory, Pareto optimality theory and contract theory on health insurance. Then the contribution and its application was analyzed with the above theories for the theory of the negotiation mechanism on the health insurance. Firstly, negotiation Theory:changing a negotiated process of cooperation to a cooperative game. Second, the value of public administration theory:negotiating used fair procedures to express fully with multiple interests in order to ensure the legitimacy and legality of decisions. Thirdly, Pareto optimality theory:the re-specification to duty-power-benefit can achieve Pareto improvement to Pareto optimal. Fourthly, the health insurance agreement can also be called the health insurance contract. The agreement management was the initial stage of health insurance negotiations. Then we can know legal relations with the subject, object and content.3. Practice Analysis:Comparing with international level, a list of the basic situation of the negotiating parties showed that our health insurer had relatively weak bargaining power, controlling costs means more backward. Inequality resulted some discord factors in the agreement management (the primary form of health insurance negotiations) for the phases of signing agreement and fulfilling agreement that increased transaction costs and reduce the health insurance fund efficiency. Combined with international research, the thesis focused on the market concentration impact on the health care negotiations, and put Hubei empirical research as an object to confirm. The medical services industry in Hubei Province reached 67.82 percent of market concentration, indicating a high degree of market concentration.The the author suggested that public hospitals can be separated regulating and running of health care organizations and set up third-party monitoring mechanism improving the efficiency of health care negotiations. Finally, in this part of the combination of health insurance status of the negotiations SWOT analysis was made. The atuthor found that the reality of health care bargaining was WO construction and development in the environment. The strategy was urgently need to improve the internal environment, external environment by using the opportunity and overcoming the disadvantage.4. Game model:Based on the general analysis of game theory combined with the characteristics of health insurance negotiations, a theoretical model was successfully built. First of all, health care payment was the core of the negotiations with the hospital. Under certain single payment method or combined method in a payment, it was the primary problem in health care negotiations to solve that how to achieve the win-win status between health insurance and hospitals and control the balance of interests in health care costs. Proposal to change the current dynamic game for the static game, can be achieved while maximizing health insurance and hospital benefits. Secondly, the negotiations in accordance with international classification, health care bargaining model can be divided into two categories:individual and collective bargaining negotiation model. Individual negotiation model:if they recognized the hospital vicious competition for the long-term results and chose not to control cost, they were bound to earn not more income.Thus for the hospitals cooperation was the best option and this was a result of cooperative game non-zero sum game. Collective bargaining model model:bilateral monopoly model and moral hazard model indeed. bilateral monopoly model showed that the rational choice was combined them together into cooperation organization. Because hospital association of moral hazard can cause the loss of the hospital, It may be prevent moral hazard and reduce loss of interest in various hospitals with threatening by the collective behavior of the hospital association. Finally, combined with new health reform-oriented, non-profit health care negotiations would be the main model for hospitals to start exploring the design of non-profit hospitals health insurance transactions. Through modeling, under the total budget conditions, the policy makers should prevent non-profit hospitals only to provide high-quality medical services in health care rather than on the number of cases. To stimulate insufficient incentives for the number of medical problems, the advice may be "by service unit". Health care payment would form a combination of a more rational health care transactions. 5. Case study:Combining theory and sample areas according to the aforementioned survey, the thesis selected typical cases related to in-depth analysis, interpretating construction and negotiation mechanism development. Case I, Zhenjiang was the first pilot city for the medical insurance system reform assigned by State Council. Some experiences were well summed up in the index fund budget and final accounts and settlement processes, quality controling of medical services, and buying medical services for a great quantity. Case II described negotiation mechanism the details by comparing the Zhenjiang's policy with Chengdu's. Case III was a dynamic health care negotiations. The new agreement would cause hospital behavior change on the next round of negotiations with the policy implications. In this part of the study, time series was used to analyze changes in behavior as an example to illustrate the hospital behavior for payment changes in a county hospital. The study found:Though health care payment paid by the project from the bed at a charge to press, there was no significant increase in medical costs and others except for medicine costs down. Negotiate payment and other important and timely attention should be given to changing circumstances in order to fast dynamic response. Case IV, In certain large hospital (star hospital) health insurance does not start because the negotiations and the adverse selection from the reality of theoretical analysis.The author suggested that if health care organizations to participate in medicare as to whether non-mandatory, large hospitals will give the insured people and the different objects, different services to adopt price discrimination to maximize profits.6. Practice rules:For the current medical insurance system reform dilemma and facing the urgent need to push health care negotiations from the theory to health care negotiating practice a set of workable rules required urgently. Through theoretical and empirical analysis, the system made workable rules of practice of health care negotiations. Established specific objectives:optimal allocation of medical resources, medical services and medicines to effectively control costs. Basic principles:the principle of maximizing the interests of the insured person, a fair balance between efficiency priority, multi-win-win physician-patient-insurer. The thesis showed the initial framework for health insurance negotiations, from the preparation stage, the formal phase of negotiations, an agreement to perform stage, regulatory and other aspects of the new requirements. Based on the above discussion, a guideline named " Summary on mechanism for building guidelines for health insurance negotiations"is formatted. Finally, guidelines for negotiating mechanisms did recognition of the extent of health care experts. A higher degree percent of overall recognition were 80%, and the reasons for its non-recognition are also analyzed and put corresponding countermeasures.7.Countermeasures to construction of health insurance negotiations:Learning from international experience, under the background of health reform in our country and our national conditions, corresponding countermeasures and suggestions was put forward from three levels among the system, organization and individual level. On the system level, a good top-level design includes "precise positioning, targeted", "scientific design ","strategic control","the implementation of place". On the organizational level, health care institutions to new ideas, the introduction of competition, and medical institutions To re-positioning, and the power to integrate, the negotiations to increase awareness and motivation.On the individual level, the moral hazard of medical practitioners must be controlled and enrollment rate of insured persons should be enhanced in the negotiations besides that the insured person should accept the main measure of education.Conclusions1. Based on situation analysis of the negotiating parties, it is shown that the bargaining power of health insurer was weaker and means of controlling costs was lagging behind. As a result, a high degree of market concentration in health care field caused public hospitals showing monopoly-oriented.2. After negotiations SWOT analysis, the construction of the mechanism of health care negotiations lay in a WO environment. That's to say, it was urgent to improve the internal environment. WO measures must to be taken by using better the opportunity and overcoming the disadvantage.3. If we changed the static game of the health insurer and medical institutions into dynamic game, these two parties can be achieved maximizing revenue at the same time under certain conditions.4. For non-profit hospitals as the main, the combination payment method may be reasonable including "by service unit" and "globe budget ".5. Whether individual or collective bargaining negotiations, it needs to change non-cooperative game into cooperative game in order to ultimately achieve Pareto optimality. 6. Negotiating workable rules of practice was made systematically. Guidelines summary for building health insurance bargaining was formed initially. And after qualitative and quantitative arguments, the outline was widely recognized and can try to implement.Innovations and meritsTheoretical innovation:Social health insurance bargaining theory research and practice has just started so that it urgently need to study. Based on the negotiation mechanism in the clear substance, the study formed the basic theoretical framework of negotiations mechanism and developed rules of practice in line with our national conditions.Innovation of methods:market concentration method was used to position the negotiating parties. Advanced SWOT analysis was identified for the development of health insurance status of the negotiations and strategies. As an empirical study, time series analysis method was adoped to track the hospital behavior after payment reform medical practices. Health insurance negotiations game of two hospitals combining behavioral synthesis modeling was constructed. These methods overcome the traditional focused on one aspect of health insurance by the limitations of methods. They could simulate the process closer to the actual process and the results were more stable. Therefore we could get more credible conclusions.Policy value:Based on China's realities, with reference to the general rules of negotiation mechanisms of the development of international health insurance, the study established a scientific framework for health care negotiation mechanism and developed appropriate rules of practice. These above had important practical value for the smooth implementation of the national health insurance negotiation mechanism. The study got rich quantitative data of health insurance negotiations. The current reality was analyzed from various views for formulation of policy-making departments to provide health insurance program policy basis for negotiation mechanism.