关于医疗费用支付方式的探讨

选择合理的医疗费用支付方式是保证医疗资源有效利用、控制医疗费用不合理增长的关键.文章讨论了按服务项目支付、按人头支付、总额预算制、按病种支付、按服务单元支付五种基本支付方式的优缺点,并对其进行比较分析,提出选择支付方式的建议.     

医疗费用支付方式的比较

选择合理的医疗费用支付方式是保证医疗资源有效利用、控制医疗费用不合理增长的关键。作者通过分析比较总额预算制、按服务项目支付、按服务单元付费、按人头支付、按病种支付和按疾病诊断分类定额预付制等多种支付方式的优劣,认为各种支付制度都是在不同情况下、为了不同目的而实行的,各有利弊。其中,按疾病诊断分类定额预付制,应是我国积极探索和研究的支付方式。     

支付方式对医疗质量的影响分析

目的:了解支付方式对医疗卫生服务质量的影响。方法:文献综述法。结果:理论上支付方式会对医务人员行为构成影响,从而间接影响到医疗服务质量;文献综述显示按项目付费、按人头付费和单病种付费等支付方式对医疗质量有影响,但不同支付方式对医疗质量的影响不同。结论:支付方式确实对医疗服务质量有影响,但支付方式对医疗服务带来的影响是正面还是负面,尚需结合疾病种类和实施条件做出判断。建议:支付方式改革时综合考虑费用控制与医疗服务质量,积极探索混合支付方式。     

韩国医疗服务支付方式改革对我国的启示

随着我国城镇职工基本医疗保险制度改革的深入，支付方式的改革越来越显得重要。我国与韩国一样，在社会医疗保险初期，支付方式都是按服务项目付费、这种支付方式导致服务数量的增加、治疗方案的扭曲，医生更愿意提供收益好的服务。为了寻求解决办法，韩国在1997年尝试实施按诊断相关分组(DRG)的支付方式。通过对韩国支付方式改革的回顾，为我国城镇职工基本医疗保险支付方式的改革提供借鉴。     

医疗服务支付方式改革利益相关者分析

医疗服务支付方式改革是医药卫生体制改革核心问题之一.支付方式能够影响医疗服务利益相关者的行为,从而对医疗费用、医疗质量、医疗服务效率和医疗保险资金使用的效益产生影响.通过对利益相关者在按服务项目支付、按诊断相关组定额预付、总额预付3种支付方式中的行为分析发现,按诊断相关组定额预付既能够切实控制费用增长,使医疗质量得到保障,又能够较好地满足支付方式改革中各利益相关者的诉求.但是,各利益相关者在按诊断相关组定额预付支付中,需要不断完善病案首页数据填报、临床路径使用、信息系统建设、成本核算、费用结构调整等方面.     

供方支付方式研究及政策建议

1978年改革后的我国实行的是按服务项目付费为主、政府预算为辅的支付方式."总量控制、结构调整"起到了一定的控制医疗费用上涨的作用.公费、劳保医疗受到按服务项目付费方式的冲击.城镇职工医疗保险制度和农村的合作医疗制度都对供方支付方式进行了一些有益的探讨.结合国内外经验,混合支付系统是供方支付方式在未来的发展趋势.     

医疗保险基金支付方式改革对医疗质量的影响分析

探讨支付方式改革在医疗质量提升及医疗费用控制中的作用,以成都市门诊特殊疾病血液透析（门特血透）为例,分析了支付方式改革的必要性。目前,门特血透支付方式已从传统按项目付费过渡到按病种定额付费,以2014年成都市内两家收治患者情况类似的三级医院为例,模拟门特血透支付方式改革后的医院运行情况。探讨支付方式的改革可以间接督促医院医疗质量的提升和服务效率的提高。应在广泛准确收集数据的基础上,根据门特血透质效评价结果对医疗机构实行按医疗质量付费。     

从国外医疗保险的发展看医疗费用的控制

一、传统医疗保险支付方式是费用上涨的加速器医疗保险的核心是医疗资金的筹集和支付。各国医疗保险制度按筹资方式不同分为国家预算制、公共保险制和个人自愿保险制,资金分别来自国家税收,国家、企业、个人三方或其中两方交纳的保险金,以及完全由个人交纳的保险金。这些资金筹集起来     

在医改语境下推进支付方式改革

预付制类型主要有总额预付制、按人头支付、按床日支付、按疾病诊断相关分组支付等。如何选择合适的支付方式来控制医疗费用的过快增长，浙江省做了些探索。     

薪酬支付方式对医生医疗行为的影响

通过比较薪酬支付方式与其他支付方式所产生的客观结果与医生的医疗行为,评价了薪酬支付方式对医生医疗行为的影响。结果发现,与按服务项目支付相比,薪酬支付在提供服务的数量方面有所不同,并且其提供的服务与不同的咨询服务模式相关。     

Incentives and provider payment methods

The mode of payment creates powerful incentives affecting provider behavior and the efficiency, equity and quality outcomes of health finance reforms. This article examines provider incentives as well as administrative costs, and institutional conditions for successful implementation associated with provider payment alternatives. The alternatives considered are budget reforms, capitation, fee-for-service, and case-based reimbursement. We conclude that competition, whether through a regulated private sector or within a public system, has the potential to improve the performance of any payment method. All methods generate both adverse and beneficial incentives. Systems with mixed forms of provider payment can provide tradeoffs to offset the disadvantages of individual modes. Low-income countries should avoid complex payment systems requiring higher levels of institutional development.     

A typology for provider payment systems in health care

A typology to classify provider payment systems from an incentive point of view is developed. We analyse the way, how these systems can influence provider behaviour and, a fortiori, contribute to attain the general objectives of health care, i.e. quality of care, efficiency and accessibility. The first dimension of the typology indicates whether there is a link between the provider's income and his activity. In variable systems, the provider has an ability to influence his earnings, contrary to fixed systems. The second dimension indicates whether the provider's payments are related to his actual costs or not. In retrospective systems, the provider's own costs are the basis for reimbursement ex post whereas in prospective systems payments are determined ex ante without any link to the real costs of the individual provider. These different characteristics are likely to influence provider behaviour in different ways. Furthermore the most frequently used criteria to determine the provider's income are discussed: per service, per diem, per case, per patient and per period. Also a distinction is made between incentives at the level of the individual provider (micro-level) and the sponsor (macro-level). Finally, the potential interactions when several payment systems are used simultaneously are discussed. This typology is useful to classify and compare different types of payment systems as prevailing in different countries, and provides a useful framework for future research of health care payment systems.     

Ambulatory care and the law: lien claims where none exist as of right

The health care provider, whether an individual or an institution, needs to pay attention to appropriate mechanisms to ensure payment for services or repayment for benefits provided. While statutes provide some protection for large institutions, including health care providers, individual health care providers often are left to their own devices. The employment of a well drafted voluntary lien agreement can not only secure a right of recover against a patient, but where the patient pursues a personal injury claim through an attorney, can also give the health care provider recourse to patient's attorney. Knowing how to assert these liens, what funds are reachable by these lien, and what time factors must be adhered to in order to make the liens effective, are vital to a health care provider's financial well-being.     

Effects of mixed provider payment systems and aligned cost sharing practices on expenditure growth management,efficiency, and equity: a structured review of the literature

Background

Strategic purchasing of health care services has become a key policy measure on the path to achieving universal health coverage. National provider payment systems for health services are typically characterized by mixes of provider payment methods with each method associated with distinct incentives for provider behaviours. Reaching incentive alignment across methods is critical to enhancing the effectiveness of strategic purchasing.

Methods

A structured literature review was conducted to synthesize the evidence on how purposively aligned mixed provider payment systems affect health expenditure growth management, efficiency, and equity in access to services with a particular focus on coordinated and/or integrated care management.

Results

The majority of the 37 reviewed articles focused on high-income countries with 74% from the US. Four categories of payment mixes were examined in this review: blended payment, bundled payment, cost-containment reward models, and aligned cost sharing mechanisms. Blended payment models generally reported moderate to no substantive reductions in expenditure growth, but increases in health system efficiency. Bundled payment schemes consistently report increases in efficiency and corresponding cost savings. Cost-containment rewards generated cost savings that can contribute to effective management of health expenditure growth. Evidence on aligned cost-sharing is scarce.

Conclusion

There is lacking evidence on when and how mixed provider payment systems and cost sharing practices align towards achieving goals. A guiding framework for how to study and evaluate mixed provider payment systems across contexts is warranted. Future research should consider a conceptual framework explicitly acknowledging the complex nature of mixed provider payment systems.

     

Patient satisfaction and selected physician behaviors: does the type of practice make a difference?

This study was designed to show what specific physician characteristics lead to patient satisfaction and to compare satisfaction of patients using either prepaid or fee-for-service modes of payment within the same settings. We surveyed 1142 patients in five family practice clinics in rural and suburban areas of the North Central United States. Regression analysis of a seven-item satisfaction scale showed four significant factors that accounted for variance: sensitivity, is on time for appointments, follows up promptly, and provides personalized medical care. No meaningful differences were found between health-maintenance-organization and fee-for-service patients on these satisfactions. This study expands findings from previous research and raises more questions about reliable rating scales for complex physician/patient relations. Our methods can be used to investigate the effects of newer types of prepaid plans (including individual practice associations and preferred provider organizations) on patient satisfaction. The challenge for future investigations is to test and build reliable predictive models showing how physician characteristics, patient satisfaction, and quality of medical care affect each other in these more complex models of practice and reimbursement.     

合约理论下医疗保险支付制度分析

医疗保险支付是保险机构同医疗服务供方订立合同,购买医疗服务的过程。保险机构希望通过合同对供方行为进行激励从而控制医疗成本。以合约理论为分析工具,对现行医疗保险支付方式进行分析,并对后付制和预付制两种支付机制的效果进行比较。提出,为了在保证医疗服务质量的同时达到费用控制的目的,单一的支付方式未必能取得良好的效果,医疗保险机构应综合利用两种支付机制的优势,达到对医疗服务供方行为监督的目的。     

Strategic Provider Behavior Under Global Budget Payment with Price Adjustment in Taiwan

Global budget payment is one of the most effective strategies for cost containment, but its impacts on provider behavior have not been explored in detail. This study examines the theoretical and empirical role of global budget payment on provider behavior. The study proposes that global budget payment with price adjustment is a form of common‐pool resources. A two‐product game theoretic model is derived, and simulations demonstrate that hospitals are expected to expand service volumes, with an emphasis on products with higher price–marginal cost ratios. Next, the study examines the early effects of Taiwan's global budget payment system using a difference‐in‐difference strategy and finds that Taiwanese hospitals exhibited such behavior, where the pursuit of individual interests led to an increase in treatment intensities. Furthermore, hospitals significantly increased inpatient service volume for regional hospitals and medical centers. In contrast, local hospitals, particularly for those without teaching status designation, faced a negative impact on service volume, as larger hospitals were better positioned to induce demand and pulled volume away from their smaller counterparts through more profitable services and products such as radiology and pharmaceuticals. Copyright © 2014 John Wiley & Sons, Ltd.     

Medical care program compliance--a year 2000 recipient perspective of Medicare claims

This article provides a brief assessment of patient and provider views and concerns regarding reimbursements under the Medicare program. Specifically targeted is the payment of pharmaceutical claims. Also addressed are the ongoing and respective responsibilities of individual clinical providers, associated hospitals, and recipients of care. A summation of significant results of direct interviews and follow-up discussions with 10 Medicare recipients also is provided.