Interaction Between Social Health Insurance And Health Care Provider

Purpose:With the coming of universal health insurance and the deepening of the new health reform, it is of great significance to make positive interactions between social health insurance and health care provider to push healthcare system reform in China. However, there are many problems in the health insurance system. This research aims to explore the relationship between social health insurance and health care provider, the influencing factors, the incentive and restraint mechanism of their interaction and provide the policy recommendations to promote positive interaction between social health insurance and health care provider.Methods:1. Literature researchBy collecting, organizing, analyzing and summarizing the literatures, the current situation of studies both at home and abroad was hold and the research idea was determined.2. Interviewing methodBy qualitative interviews and consultation among the insurers, managers of medical institutions, medical staff and experts, the research idea and methodology was revised and it provided the foundation for questionnaire design.3. Questionnaire surveyThe survey areas including Shenzhen, Shanghai, Hubei, Jiangxi, Sichuan and Chongqing were selected according to geographic region of the East, the Central and the West in China. Totally480medical staff questionnaires and60insurers questionnaires were sent out. The data were analyzed by SPSS13.0, specific methods include:①To analyze the current situation and characteristic of the interaction between the health insurer and health care provider by descriptive statistic;②To explore the influencing factors of interaction by factor analysis.4. Case studySome typical case were collected and studied, such as the interaction between health insurance reform and healthcare reform, New Rural Cooperative Medical Scheme how to promote the development of health care system, payment method reform of New Rural Cooperative Medical Scheme and hospital how to adapt to the transformation of development pattern of health insurance system.Results:1. There are two forms of performance for the interaction between health insurance and health care providers:positive interaction and non-positive interaction. The problems existing in the interactions between social health insurance and health care provider are:the high pressure of health insurance expense control, the weakness of social capital, the non-cooperation relationship between the social health insurance and health care provider and the high transaction cost.2. The influencing factors of the interaction between social health insurance and health care provider are social capital, social actor power, transaction cost, default control, value orientation and negotiation frequency. There are significant differences between transaction cost, value orientation, social capital and default control in different region (p<0.05). There are significant differences between transaction cost in different level medical institutions (p<0.05). There are significant difference between transaction cost factor and value orientation factor in the person with different job title (p<0.05). Gender and education background have no effect to the interactions between social health insurance and health care provider.3. The system of incentive and restraint mechanism of interactions between social health insurance and health care provider includes negotiation mechanism, health insurance payment mechanism, assessment and evaluation mechanism, information disclosure mechanism and external supervision mechanism.Conclusions:1.The health insurance reform should be pushed forward synchronously with the health care reform, promoting the positive interaction between health insurance and health care provider, then the health care reform can finally be succeed.2.The following reform measures should be promoted:promoting the laws and regulation construction of health insurance; pushing forward the revolution of medical service system through the effect of health insurance; establishing the monitoring and analyzing system of health insurance fund; exploring the payment method of ’pay for performance’; shaping a healthy social cooperative culture. Innovations:1. By applying a multidisciplinary perspective and using the theories and methods of sociology, economics and management to analyze the natures, principles, mechanisms and contents of the interactions between social health insurance and health care provider, a theoretical analytical framework of the interaction is established and it offers a methodological guidance for the construction of the positive interaction between social health insurance and health care provider.2. Exploring the influencing factors of the interaction between social health insurance and health care provider from the qualitative and quantitative aspects and combined with the cases studies, the practice performance of the interaction is interpreted to provide evidence for valuing the interaction between social health insurance and health care provider during the health reform.3. By establishing an incentive and restraint mechanism to promote the positive interaction between social health insurance and health care provider, it plays a role of enlightenment for the health decision and health management practice.Limitations:1. The questionnaires survey of insurers is a small sample size.2. There is no study on interaction evaluation between social health insurance and health care provider.