基本医疗保险“欺诈骗保”现象的影响因素及路径研究——基于我国31个省级案例的清晰集定性比较分析

目的：探索欺诈骗保现象发生的关键因素和路径，为我国医保基金监管改革和欺诈骗保现象的治理提供依据。方法：基于史密斯政策执行理论，利用国家审计署、国家医保局公布的110起典型案件，通过清晰集定性比较分析方法，分析欺诈骗保的关键因素和路径。结果：我国欺诈骗保主体和手段主要包括经办机构超范围支付、公立医院自立收费项目或提高收费标准、民营医院和基层卫生机构虚构住院、定点药店上传虚假销售记录以及参保人重复报销等。当地监管政策制定情况、民营和基层医疗机构、居民收入水平、主政官员工作经历、监管技术水平以及医保基金充裕程度是影响骗保现象发生的前因条件，并形成了目标群体妨碍、执行机构失守、政策表面执行和强监管—高发现的骗保路径。结论：目标群体妨碍是我国欺诈骗保发生的重要主体和路径，应加强经济水平较低地区的民营和基层医疗机构治理。执行机构失守从主动和被动两方面加剧了欺诈骗保发生，需通过完善医保监管体制和监管技术方式以提高监管机构能力和水平，避免政策表面执行等问题。

Study on the paths of basic medical insurance frauds and their influencing factors: A crisp-set qualitative comparative analysis of 31 provinces in China

Objective: To explore the key factors and paths of basic medical insurance frauds, and provide a basis for the reformin the supervision of China''s medical insurance fund and the treatment of fraudulent insurance cases found in the basic medical insurance system. Methods: Using data from the 110 typical cases announced by the National Audit Office and the National Health Security Administration, clear set of qualitative comparative analysis (csQCA) were used to analyze the effects of potential factors and paths of medical insurance frauds based on the Smith policy implementation theory. Results: The main bodies and methods of insurance fraud include over-payment by agencies, self-supporting charging items or raising charging standards in public hospitals, fictitious hospitalizations in private hospitals and primary healthcare institutions, uploading false sales records in designated pharmacies, and repeated reimbursements of insured persons, etc..The formulation of local regulatory policies, private and primary healthcare institutions, residents'' income level, leading officials'' work experience, the regulatory technology level, and the balance of medical insurance funds were the key conditions affecting the occurrence of fraudulent cases inmedical insurance. Four types of paths of insurance fraud were found to be obstacles including the target groups, failure of enforcement agencies, superficial implementation of policies, and strong supervisionor a high-detection of fraudulent insurance path.Conclusions: The target group obstructions is an important subject and path for insurance fraud in China. The governance of private and primary heathcare institutions in areas with lower economic levels should be strengthened. The failure of enforcement agencies has aggravated the occurrence of insurance fraud from both active and passive aspects.Therefore, it is necessary to improve the medical insurance regulatory system and regulatory technical methods to improve the capabilities and levels of insurance monitoringand avoid superficial implementation of policies.