欺诈骗保风险暴露的组态路径研究&#x02014;&#x02014;基于省级截面数据的fsQCA分析

王美娇; 邵金龙; 朱铭来; 徐晨

doi:10.19546/j.issn.1674-3830.2026.7.003

中国医疗保险 ›› 2026, Vol. 0 ›› Issue (7) : 18-28. DOI: 10.19546/j.issn.1674-3830.2026.7.003

观察思考

欺诈骗保风险暴露的组态路径研究——基于省级截面数据的fsQCA分析

王美娇^1,2, 邵金龙¹, 朱铭来², 徐晨¹

作者信息 +

Research on the Configurational Paths of Risk Exposure in Basic Medical Insurance Fraud—An FsQCA Analysis Based on Provincial Cross-Sectional Data

Author information +

文章历史 +

摘要

目的: 探究省域基本医疗保险基金欺诈骗保风险暴露的组态生成路径,为医保基金分类监管和精准治理提供参考。方法: 基于2023年我国31个省级行政区截面数据,选取经济发展水平、老龄化水平、基金支出压力、信息化设施水平和医疗服务供给复杂度五个条件变量,以日常活动理论为基础构建分析框架,运用fsQCA方法开展组态分析。结果变量以每10万参保人对应的查处违法违规人员数衡量,反映医保违法违规行为经监管识别、查处和记录后的省域查实暴露水平。结果: 单一条件及其非集均不构成欺诈骗保风险暴露的必要条件。省域欺诈骗保风险高暴露存在“高基础—高压力—高信息化基础型”“低基础—高压力—低信息化基础型”和“低基础—老龄化—信息化供给复杂型”三条路径。结论: 欺诈骗保风险暴露具有多条件并发和路径差异化特征。信息化设施水平可能通过增强就医购药和医保结算记录的数据留痕,影响违法违规行为的发现和查实。医保基金监管应根据不同地区风险暴露机制实施分类治理。

Abstract

Objective: The paper attempts to investigate the configurational pathways of provincial-level medical insurance fund fraud risk exposure and provide policy implications for classified supervision and precise governance of medical insurance funds. Methods: Based on 2023 cross-sectional data from 31 provincial-level administrative regions in China, this study selected five condition variables: economic development level, aging population level, fund expenditure pressure, information infrastructure level, and complexity of healthcare service supply. Drawing on Routine Activity Theory, this study constructed an analytical framework and employed fuzzy-set qualitative comparative analysis (fsQCA) to identify configurational paths. The outcome variable was measured as the number of investigated and confirmed violators per 100000 insured persons, reflecting the provincial-level verified exposure level of medical insurance violations after regulatory identification, investigation, and recording. Results: No single condition or its negation constitutes a necessary condition for medical insurance fund fraud risk exposure. Three configurational paths for provincial high-risk exposure were identified: "high foundation-high pressure-high IT infrastructure type", "low foundation-high pressure-low IT infrastructure type", and "low foundation-aging-complex service supply type". Conclusions: Medical insurance fund fraud risk exposure is characterized by multi-condition conjunctive causation and path heterogeneity. Higher levels of information infrastructure may enhance the traceability of medical service utilization and billing, facilitating the detection and verification of fraudulent behaviors. The supervision of medical insurance funds should adopt classified governance based on the risk exposure mechanisms specific to different regions.

导出引用

王美娇, 邵金龙, 朱铭来, 徐晨. 欺诈骗保风险暴露的组态路径研究——基于省级截面数据的fsQCA分析[J]. 中国医疗保险. 2026, 0(7): 18-28 https://doi.org/10.19546/j.issn.1674-3830.2026.7.003

Research on the Configurational Paths of Risk Exposure in Basic Medical Insurance Fraud—An FsQCA Analysis Based on Provincial Cross-Sectional Data[J]. China Health Insurance. 2026, 0(7): 18-28 https://doi.org/10.19546/j.issn.1674-3830.2026.7.003

中图分类号： F840.684C913.7

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