国内外医疗体制与付费方式适配理论的反思和创新

医疗服务体制机制和医疗保险付费方式的制度适配是医药卫生体系充分发挥功能的根本前提。国外医疗服务体制机制与医疗保险付费方式的五大适配理论,国内医疗服务体制机制与医疗保险付费方式的四大适配理论,对我国公立医院体制机制与医疗保险付费方式的协同改革均具有重要的借鉴价值。然而,国内外研究成果较多关注"医疗服务体制机制如何适应医疗保险付费方式"的方面,而较少关注"医疗保险付费方式如何改造医疗服务体制机制"。文章提出医疗保险付费方式如何改造医疗服务体制机制的基本思路。     

医疗保险费用支付方式的选择分析

医疗保险付费方式与医疗费用的控制有确切的关系,同时还涉及患者的救治及医疗服务的质量.本文探讨目前医疗保险付费方式的相应方法,并介绍各种付费方式的优缺点和适用情况.探讨适合我国国情的医疗费用支付方式.     

国外医疗体制机制与医保付费方式的适配理论

医疗服务体制机制和医疗保险付费方式的制度适配是医疗卫生体系充分发挥功能的根本前提。文章从国外行政学、管理学、经济学中提炼出医疗服务体制机制与医疗保险付费方式的五大适配理论:政府购买服务理论、有管理的竞争理论、花钱矩阵理论、责权利均衡理论、激励相容理论,为我国公立医院体制机制与医疗保险付费方式的协同改革提供理论参考。     

不同付费方式下基层医疗卫生机构医疗收入会计核算方法

现在多数地区医疗保险部门实行按医疗项目付费,但总额预付制也已经在一些先行地区试行,医疗保险部门依据确定的费用总额,向基层医疗卫生机构支付病人的医疗费用,不再按医疗项目收费标准进行结算。另外,按病种付费、按人头付费在一些地区都有试行。付费方式的改变,要求基层医疗卫生机构医疗收入的会计核算方法必须与之相适应。现根     

九江市职工医疗保险费用支付方式回顾与评述

职工医疗保险制度改革 ,医疗费用支付方式是医疗保险运转中重要的组成部分 ,是改革的重点和难点。我市在深化医疗保险制度改革的 5年实践中 ,结合本地实际情况 ,不断探索、改进和完善医疗费用支付办法 ,主要经历了 (1)按项目付费“通道式”付费方式 ;(2 )“三项”动态均值“通道式”付费方式 ;(3)“三项”定额“板块式”付费方式 ;(4 )总量控制、定额包干“板块式”付费方式四个阶段。实践证明 ,新的费用支付方式对控制医疗费用 ,保证统筹基金收支平衡 ,规范医疗服务行为 ,保障职工的基本医疗 ,起到了一定的作用。但也存在诸多不足 ,有些问…     

国内医疗体制机制与医疗保险付费方式的适配理论

医疗服务体制机制和医疗保险付费方式的制度适配是医药卫生体系充分发挥功能的根本前提。本文从分散、零碎的国内"医改"研究成果中整合和总结出医疗服务体制机制与医疗保险付费方式的四个适配理论:三医联动理论、供给主导理论、需求主导理论、权变策略理论,在阐明主要内容的基础上分析各理论的指导意义和逻辑缺陷,为我国公立医院体制机制与医疗保险付费方式的协同改革提供理论参考。     

公立医院放任型市场化机制与医疗保险项目制后付费方式的错配分析

公立医院体制机制与医疗保险付费方式的功能适配决定公立医院体制机制与医疗保险付费方式的协同改革。公立医院体制机制与医疗保险付费方式的适配性可以从扩大医疗数量、控制医疗费用和保障医疗质量三个方面进行分析。公立医院的放任型市场化机制尽管在"扩量"方面适配医疗保险的项目制后付费方式,但是在"控费"方面错配医疗保险的项目制后付费方式,在"保质"方面错配医疗保险的项目制后付费方式。因此,公立医院的放任型市场化机制"基本错配"医疗保险的项目制后付费方式。     

医疗保险支付制度改革与医院成本核算发展趋势探讨

本文从医疗卫生服务供方、需方和费用支付方分析了影响医疗保险制度的因素。论述了医疗保险支付制度改革方向的特点，即医疗保险费用支付将从开放式向封闭式发展、费用支付组合从单一支付方式向多元化混合支付方式发展、医疗保险控费主体由费用控制中心向以资源控制中心发展。因此，我国现行医疗保险必须改革单一的按服务项日付费的支付方式，采取多种付费方式，并建立相应的配套措施。同时，医院医疗成本核算应建立包括科室成本核算、医疗项目成本核算和病种成本核算在内的医疗成本核算体系。     

对医疗保险付费方式改革的总认识

医疗保险付费方式改革不仅是我国医保体制改革的重要内容,也是我国医疗体制改革的重要内容。深化医疗保险付费方式改革,既要把握医疗保险付费方式的类型、功能和本质,更要领悟医疗保险付费方式改革的根源、目标和路径。     

医疗保险中实施DRGs的探讨

随着医疗改革的不断深入,社会医疗保险制度的建立与完善,在医疗保险中建立科学、合理的管理模式和付费方式是非常重要的。DRGs作为医疗费用预付制度,已被世界许多国家在医疗保险中所采用,并收到了良好的效果。因此,探讨DRGs在我国的医疗保险中的应用具有十分重要的意义。 一、DRGs的概念 DRGs是美国在1976年首创的一种具有挑战性的医疗     

Prospective payment in-service presentation for nurses

This was a brief overview of the prospective payment system. Again, this overview was designed as a tool for an in-service educational program. Certainly not all of the complexities of the prospective payment system were discussed in this article. Many more items could be expanded upon, such as attestation, length of stay, and coding functions. At the end of the presentation, it is suggested that you invite the nursing staff to your department to view the coders and/or the utilization review process. An orientation to the HIM or Medical Record Department for the nursing staff could be an excellent way to open the door for more communication and teamwork.     

医院信息化中收费问题的研究

目的：研究医疗收费过程中遇到的问题,主要是如何自动区分缴费主体。方法：基于“军卫一号”软件实际应用情况,分析了国内医疗收费的现状,设计了单病种收费机制和能普遍适应各种医保政策的收费机制,并描述其费用分解流程。结果：费用分解流程能够很好地适应国内各地不同的医疗支付政策,具备高度的灵活性,并在解放军总医院新版门诊收费系统中获得成功应用。结论：解决了医疗收费中常见的主要问题,其费用分解流程在国内各地区复杂多变的支付政策环境下具有普遍适应性。     

医疗保险制度改革对医院就诊病人医疗费用的影响分析

该文通过对上海市医疗保险制度改革实施前后,医院就诊病人次均医疗费用、费用构成及自负比例等方面变化的统计分析,阐述了医疗保险制度改革的积极效果,提出在深化医疗保险制度改革的同时,还要照顾到弱势群体,同时医院应加强对自费病人的管理。     

定额付费对剖宫产率影响的实验研究

目的:当前剖宫产率过高已成为严重的公共卫生问题。通过该实验来验证定额付费对医院降低剖宫产率的作用,为新医改政策的落实提供实证依据。方法:对参合孕产妇住院分娩实行定额付费,即:不论平产、阴道助产、剖宫产均支付同等数额的住院费用。将定额付费作为实验因素,观察干预组与对照组、干预组实施前后剖宫产率、平均住院费用和死亡率等指标变化。结果:干预地区实施该方法后剖宫产率降低14.08个百分点,平均住院费用降低33.96%。结论:改革付费机制,可以有效改变医院的行为,达到降低剖宫产率、控制费用和提高医疗质量三重目的。     

The treadmill effect in a fixed budget system

We examine the interaction in the market for physician services when the total budget for reimbursement is fixed. Physicians obtain points for the services they render. At the end of the period the budget is divided by the sum of all points submitted, which determines the price per point. We show that this retrospective payment system involves -- compared to a fee-for-service remuneration system -- a severe coordination problem, which potentially leads to the "treadmill effect". We argue that when market entry is possible, a budget can be efficiency enhancing, if in addition a price floor is used.     

Medicare prospective payment without separate urban and rural rates

The elimination of urban-rural differences in the Medicare prospective payment system (PPS) standard rates implies a need to re-examine all the PPS payment adjustments. Refinements for case mix, outliers, and the wage index can make a significant contribution to avoiding payment disparities in a single-rate system. However, changes in the adjustments for teaching and disproportionate-share (DSH) hospitals are also needed. The typically urban location of these hospitals makes it difficult to balance PPS payments and costs among major groups of urban and rural hospitals without some form of higher payment for all hospitals located in large urban areas.     

The PROMETHEUS bundled payment experiment: slow start shows problems in implementing new payment models

Fee-for-service payment is blamed for many of the problems observed in the US health care system. One of the leading alternative payment models proposed in the Affordable Care Act of 2010 is bundled payment, which provides payment for all of the care a patient needs over the course of a defined clinical episode, instead of paying for each discrete service. We evaluated the initial "road test" of PROMETHEUS Payment, one of several bundled payment pilot projects. The project has faced substantial implementation challenges, and none of the three pilot sites had executed contracts or made bundled payments as of May?2011. The pilots have taken longer to set up than expected, primarily because of the complexity of the payment model and the fact that it builds on the existing fee-for-service payment system and other complexities of health care. Participants continue to see promise and value in the bundled payment model, but the pilot results suggest that the desired benefits of this and other payment reforms may take time and considerable effort to materialize.     

美国医疗服务价格动态调整机制及启示

建立科学合理的医疗服务价格动态调整机制是当前公立医院改革的重点方向,本文深入分析了美国医疗服务价格改革历史、动态调整参与主体和流程以及美国医疗服务价格改革的发展趋势。同时,对我国当前医疗服务价格调整存在的问题进行了剖析,并提出了建立多方参与的医疗服务价格动态调整模式;建立医疗服务项目标化点值体系,加强医保支付标准建设;逐步转变现行按项目支付模式,逐步建立DRGs和按绩效付费机制等政策建议。     

Payment systems for health care providers in Latin America and OECD countries]

The system used to pay health services providers is one of the most important components of the contractual relationship between persons who receive health services and the individual practitioners and institutions that provide those services. That payment system is also relevant in assessing a health system, including its efficiency and quality. In this article we present a simple analytical framework for various payment systems. We also provide an overview of the payment approaches used in two groups of countries whose experiences we consider representative: 10 nations of the Organization for Economic Cooperation and Development (OECD) and four countries of Latin America. We present a basic model to characterize the different forms of payment based on two dimensions. One of the dimensions is the payment "unit," which is used to measure the amount of health care services provided or promised. The other dimension is the distribution of financial risks between the service provider and the service purchaser. Each payment system has advantages and disadvantages that should be evaluated in relation to the intended objectives. On one extreme of the approaches is fixed remuneration, without any adjustments; it represents the purest prepayment approach. One example of fixed remuneration is capitated payment, in which providers carry all the financial risks coming from the variability in the cost of providing services. On the other extreme is fee-for-service payment, where service providers are not at financial risk; the insurer or other financing institution carries all the risk from variable costs. Neither of the extremes appears to be the best choice, and so the issue becomes one of selecting a remuneration system that falls between those extremes. Therefore, it is necessary to choose, on the one hand, the optimal payment unit according to the objectives of the financing entity and, on the other hand, a risk distribution approach that allocates to the service provider the risks coming from greater or less efficiency in delivering services.     

河南省宜阳县供方支付制度改革效果评估

目的：分析河南省宜阳县支付制度改革的做法和效果。方法：通过机构现有资料与数据收集,对宜阳县支付制度改革机构覆盖、费用与用药情况进行分析。结果：新的支付方式覆盖率在县医院超过65％,药占比与抗生素使用率持续降低,住院收入的平均增长速度（6％）低于医院整体收入增速（9．8％）。结论：宜阳县的支付制度改革覆盖面较高,是宜阳县目前改革的突出成果之一,部分改革效果指标已经出现良好的发展趋势。但改革依然处于起始阶段,需要进一步关注支付病种数量、覆盖面的变化,以及可能出现的住院和门诊患者之间的成本转移情况,同时改进支付标准测算方法,进行精细化管理,以实现改革目标。