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 isof great significance to make positive interactions between social health insurance and health careprovider to push healthcare system reform in China. However, there are many problems in thehealth insurance system. This research aims to explore the relationship between social healthinsurance and health care provider, the influencing factors, the incentive and restraint mechanism oftheir interaction and provide the policy recommendations to promote positive interaction betweensocial health insurance and health care provider.Methods：1. Literature researchThe current situation of studies both at home and abroad was hold and the research idea wasdetermined by collecting, organizing, analyzing and summarizing the literatures,.2. Interviewing methodThe research idea and methodology was revised and it provided the foundation for questionnairedesign by qualitative interviews and consultation among the insurers, managers of medicalinstitutions, medical staff and experts.3. Questionnaire surveyThe survey areas including Shenzhen, Shanghai, Hubei, Jiangxi, Sichuan and Chongqing wereselected 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 analyzedby SPSS13.0, specific methods include:①To analyze the current situation and characteristic of theinteraction between the health insurer and health care provider by descriptive statistic;②Toexplore 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 thedevelopment of health care system, payment method reform of New Rural Cooperative MedicalScheme and hospital how to adapt to the transformation of development pattern of health insurancesystem.Results：1. There are two forms of performance for the interaction between health insurance and healthcare providers: positive interaction and non-positive interaction. The problems existing in theinteractions between social health insurance and health care provider are: the high pressure of healthinsurance cost control, the weakness of social capital, the non-cooperation relationship between thesocial health insurance and health care provider and the high transaction cost.2. The influencing factors of the interaction between social health insurance and health careprovider are social capital, social actor power, transaction cost, default control, value orientationand negotiation frequency. There are significant differences between transaction cost, valueorientation, social capital and default control in different regions (p<0.05). There are significantdifferences between transaction cost in different level medical institutions (p<0.05). There aresignificant differences between transaction cost factor and value orientation factor in the personwith different job title (p<0.05). Gender and education background have no effect to the interactionsbetween social health insurance and health care provider.3. The system of incentive and restraint mechanism of interactions between social healthinsurance and health care provider includes negotiation mechanism, health insurance paymentmechanism, assessment and evaluation mechanism, information disclosure mechanism and externalsupervision mechanism.Conclusions:1.The health insurance reform should be pushed forward synchronously with the health carereform, promoting the positive interaction between health insurance and health care provider, thenthe health care reform can finally be succeed.2.The following reform measures should be promoted: promoting the laws and regulationconstruction of health insurance; pushing forward the revolution of medical service system throughthe 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 socialcooperative culture.Innovations：1. A theoretical analytical framework of the interaction is established, and it offers amethodological guidance for the construction of the positive interaction between social healthinsurance and health care provider by applying a multidisciplinary perspective and using thetheories and methods of sociology, economics and management to analyze the natures, principles,mechanisms and contents of the interactions.2. By exploring the influencing factors of the interaction between social health insurance andhealth care provider from the qualitative and quantitative aspects and combined with the casesstudies, the practice performance of the interaction is interpreted to provide evidence for valuing theinteraction between social health insurance and health care provider during the health reform.3. It plays a role of enlightenment for the health decision and health management practice byestablishing an incentive and restraint mechanism to promote the positive interaction between socialhealth insurance and health care provider.Limitations：1. The questionnaires survey of insurers is a small sample size.2. There is no in-depth study on interaction evaluation between social health insurance andhealth care provider.