在框架性规则和集体合同确保法定医疗保险制度统一性、底线公平性的同时,疾病基金和医疗服务提供者之间的自由协商和选择性合同又为系统注入了灵活性和多样性。疾病基金可以绕过医师协会,依据实际情况与单个医疗服务供给者或特定医生群体通过进一步协商签订选择性合同。选择性合同往往着眼于提高治疗的质量和效率,对于被保险人来说可能更具有针对性,更加符合特定人群的个性化需求。尽管目前集体合同仍占绝对主导地位,选择性合同的引入仍然提供了更多的选择性和可能性,对于集体合同来说不啻为一种有益的补充。
本文以疾病基金与门诊服务提供者之间的互动关系作为研究对象,仅呈现了德国医疗保险的部分面貌,但已不难看出其以自治管理为鲜明特色的组织体制。国家对于疾病基金与门诊服务提供者间订立的契约仅进行法律监督,具体的实施和细节拟定则交由自治管理主体。从理论上说,完全由自治机构以协商的方式组织实施医疗保险制度,并不一定能配合整体社会保障制度的运行。为此,法定医疗保险在制度机制上采取了权责再划分的设计。根据不同的功能,设置各种协商团体,并赋予谈判双方平等的法律地位,试图在制度、程序上实现彼此的制衡。同时以中立的委员会(共同自治管理组织)颁布指令,以中立的调解机构处理谈判的争议。各类谈判程序明确,透明度高。谈判结果以集体合同为主,以保证医疗服务质量为重点。分层次进行的谈判确保医疗保险系统统一性和灵活性结合,在维护社会公平的同时适应多变而灵活的医疗服务需求。可以说,德国自治管理下的医疗保险谈判在塑造国家、市场和医疗保险系统间的理性关系,维系医疗保险系统内部利益相关者的良性互动,以及保障医疗保险制度平稳和有效运行方面发挥了重要作用。
作者简介:华颖,中国人民大学2010级博士研究生,主要研究方向:医疗保险理论与政策,社会保险管理体制,社会风险与灾害问题等。
参考文献:
[1]Alle gesetzlichen Krankenkassen[EB/OL].http://www.gkv-spitzenverband.de/krankenversicherung/krankenversicherung_grundprinzipien/alle_gesetzlichen_krankenkassen/alle_gesetzlichen_krankenkassen.jsp
[2]BECKER, Ulrich, BUSSE, Reinhard. 2007. Social Security Systems in Germany Status Quo and Recent Developments. MPISoc Working Paper 2/2007.
[3]Burau, V Negotiating Reform at an Arm's Length from the State: Disease Management Programmes and the Introduction of Clinical Standards in Germany. Health Economics, Policy and Law, 4 (3), pp. 347-365.2009
[4]Gerlinger, Thomas. Health Care Reform in Germany [J]. German Policy Studies 6(1):107-142, 2010.
[5]Health expenditure [EB/OL].https://www.destatis.de/EN/FactsFigures/SocietyState/Health/HealthExpenditure/Tables/SourcesOfFunding.html
[6]John Nash, Two-Person Cooperative Games, Econometrica, Vol. 21, No. 1 (Jan., 1953), pp. 128-140,1953.
[7]Ognyanova, Diana and Reinhard Busse. Health Fund now operational. Health Policy Monitor, May 2009. Available at http://www.hpm.org/survey/de/a13/3.
[8]Saltman R. B., Busse R., Figueras J. Social health insurance systems in western Europe [M]. Buckingham, Open University Press, 2004.
[9]Schwartz, F. W. and Busse, R. Fixed budgets in the ambulatory care sector: the German experience, in F. W. Schwartz, H. Glennerster and R. B. Saltman (eds) Fixing Health Budgets: Experience from Europe and North America [M], pp. 93108. London: Wiley. 1996.
[10]Tanja Klenk, Philine Weyrauch & Alexander Haarmann. Beyond Policy Reforms: Governance Reforms in the Health Insurance Sector-Germany, France, and the Netherlands Compared. ERI Working Paper Series 08-09.2008.
[11]Urban, H.-J. Wettbewerbskorporatistische Regulierung im Politikfeld Gesundheit. Der Bundesausschuss der rzte und Krankenkassen und die gesundheitspolitische Wende (Berlin Social Science Research Centre (WZB), Working Group Public Health, Discussion Paper P01-206), Berlin: Social Science Research Center. 2001.
[12]Wendt C., Rothgang H., Helmert U. The selfregulatory German health care system between growing competition and state hierarchy. TranState Working Papers, 32, 2005.
[13]Urban, H.-J. Wettbewerbs korporatistische Regulierung im Politikfeld Gesundheit. Der Bundesausschuss der rzte und Krankenkassen und die gesundheitspolitische Wende (Berlin Social Science Research Centre (WZB), Working Group Public Health, Discussion Paper P01-206), Berlin: Social Science Research Center, 2001.
[14]Tanja Klenk, Philine Weyrauch & Alexander Haarmann. Beyond Policy Reforms: Governance Reforms in the Health Insurance Sector-Germany, France, and the Netherlands Compared. ERI Working Paper Series 08-09, 2008.
[15]John Nash, Two-Person Cooperative Games, Econometrica, Vol. 21, No. 1 (Jan., 1953), pp. 128-140, 1953.
[16]Tanja Klenk, Philine Weyrauch & Alexander Haarmann. Beyond Policy Reforms: Governance Reforms in the Health Insurance Sector-Germany, France, and the Netherlands Compared. ERI Working Paper Series 08-09, 2008.
[17]Rainer Hess. The history of using quasi-governmental entities in health care and the function of the German Federal Joint Committee[EB/OL]. http://www.academyhealth.org/files/international/2009/Hess.pdf.