通讯作者: 顾亚明, wstgym@126.com

DOI：10.12201/bmr.202506.00002

Formative Pathways of Medical Insurance Fund Reserves in County Medical Communities: A Transaction Cost Theory Perspective

• 摘要：医保基金“总额付费、结余留用、合理超支分担”是推动县域医共体高质量发展的核心制度，从实操角度重点是解决医保基金结余形成的来源渠道和医保基金留用的全过程管理等两个问题。本文基于交易成本理论，从医共体内部组织特征和外部医保支付设计等视角构建了县域医共体医保基金结余形成的分析框架，并结合浙江省德清县的典型研究，提出了厘清医保结余来源渠道、科学预算区域医保总额、医共体总额打包支付、统分结合多元付费、结算考核激励奖惩等五个方面的建议，探索医共体医保基金结余形成路径，以期为医保支付赋能县域医共体高质量发展提供理论依据与实践参考。

  关键词： 县域医共体；医保支付；结余；形成路径；交易成本; ; ; ; 

   

  Abstract: The “capitation payment with retained savings and shared accountability for reasonable overruns” mechanism constitutes a pivotal institutional framework for advancing the high-quality development of County Medical Communities(CMCs). This study addresses two critical operational challenges: identifying the sources of medical insurance fund reserves and optimizing the governance of fund retention processes.Grounded in transaction cost theory, we develop an analytical framework examining the formation of medical insurance fund reserves through the dual lenses of intra-organizational dynamics within CMCs and external medical insurance payment mechanism design.Utilizing Deqing County, Zhejiang Province as an empirical case, this research proposes a five-pronged strategy: (1) Clarifying generation channels of insurance fund reserves, (2) Scientifically determining regional medical insurance budgets, (3) Implementing bundled payment mechanisms for CMCs, (4) Adopting hybrid payment models integrating unified and differentiated approaches, and (5) Establishing performance-based incentive systems. These findings elucidate the formative pathways of medical insurance fund reserves while offering theoretical and practical insights for enhancing payment system reforms to support CMC development.

  Key words: County medical communities; Medical insurance payment; Savings; Formative pathways; Transaction cost

  提交时间：2025-06-03

  版权声明：作者本人独立拥有该论文的版权，预印本系统仅拥有论文的永久保存权利。任何人未经允许不得重复使用。
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• 序号	提交日期	编号	操作
  1	2025-04-15	bmr.202506.00002V1	下载

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