The Research On Medical Isurance Payment Mode In Shanghai Under The Background Of New Medical Reform

The medical insurance payment is the valve of medical cost control, used as aleverage to regulate medical resource, which is an essential part of medical insurance.Options of medical insurance payment will greatly impact medical services and thepatients who joined medical insurance. Therefore, the medical insurance payment reform isregarded as the central link in the second stages of the new medical reform, which is thevital section for a sustainable medical insurance system, and the success of the newmedical reform.Therefore, Shanghai City medical insurance payment model is the research object.This research identifies the developing history and current circumstances of Shanghai Citymedical insurance payment model through theoretical analysis, empirical analysis andcomparative research. The current Shanghai medical insurance payment model, which canalso be called “invert-ping of Chinese Character”, was the combination of the total budgetmanagement and three main mechanisms. The total budget management and three mainmechanisms are the two specialties in medical insurance payment; the mixed payment isthe core of Shanghai City medical insurance payment model, including payment accordingto fee for service, fee for bed unit, DRGs and budget control and so on. Shanghai medicalinsurance fund can function well, especially in controlling medicine fees. However, someproblems such as less emphasis were placed on DRG.According to the problems described above, and challenges raised from implementingFamily doctors and Medical Consorfia under the background of new medical reform, amodified model of medical insurance payment in Shanghai can be designed from fourdimensions: the objective of payment, the subject of payment, the way of payment and thestandard of payment. As for the objective of payment, the medical insurance paymentshould control unreasonable expenditure raise and ensure to provide good medical service rather than only focus on expenditure control. Two recommendations focusing on the dualrole of the subject of payment can be reached. Firstly, promote the reform ofde-administrativization, incorporation and professionalization in medical insuranceagencies. Secondly, according to Principal--agent theory, the payment service can beentrusted to commercial insurance companies and buy payment service from them. As forthe way of payment, according to the characteristics of the payment objects, a newpayment method can be developed on the basis of the former mixed payment model,including the specific payment to Community Health Center, Family doctors and thesecond and third level hospitals. As for the standard of payment, calculating the cost ofmedical services should be emphasized in order to provide objective and fair paymentstandard. Finally, an operation scheme will be raised to improve medical insurancepayment model, which requires considering stakeholders profits, improving servicecapacity through the reform of the subject of payment, implementing the mix payment andoffering supporting measures to Shanghai medical insurance payment.