美国责任医疗组织的制度设计与启示

责任医疗组织(ACOs)是美国的一种新兴卫生保健服务提供模式,《保护患者和平价医疗法案》(ACA法案)实施后在美国发展迅速。ACOs的提出是为了改变美国医疗服务碎片化的状况,并控制美国卫生费用,提高费用的使用效率。ACOs采取结余共享计划,联邦医疗保险与医疗服务中心打分测评ACOs的服务绩效和质量,ACOs信息共享与公开。ACOs模式鼓励市场自发建立医疗联合体整合卫生资源,收益分红激发卫生服务提供者的积极性,签订长期合同促使供方关注受益人健康水平,量化的卫生服务质量评价与收入直接挂钩促进质量提高,这些改革思路值得我国医疗领域借鉴。     

关注出院服务质量 改善医疗服务连续性

通过文献学习，对美国、英国、加拿大、澳大利亚等国出院服务、出院计划和出院报告的研究和实践经验进行综述。指出改善我国出院服务质量是提高区域内医疗服务连续性和卫生资源利用效率、改善患者健康结果的重要策略，这个改变需要宏观系统的支持。     

我国基本医疗连续性服务体系的构建

通过对目前连续性医疗服务的特征、意义以及影响服务连续性提供的因素进行探讨．并结合我国卫生服务提供系统的内、外部环境和相关的政策．从宏观上提出了一种连续性服务模式．构建这一连续性医疗服务提供模式，旨在使卫生服务供求关系趋向平衡，降低卫生费用和病人负担，提高卫生资源利用率，使病人能得到更好的医疗服务。     

医疗价格过快增长的供需原因与对策

在医疗费用增长的因素中，医疗价格过快增长是其中的主要原因而影响医疗价格上涨的根本原因则在于我国卫生资源相对短缺而导致的医疗供需失衡．为有效控制医疗价格的过快增长，一方面要理顺医疗筹资渠道，增加卫生资源总量，缓解医疗服务市场的供需矛盾；另一方面，要对现有的卫生资源进行合理配置，利用保险投资和市场竞争机制，提高医疗资源的利用效率。     

基于区域卫生信息平台的医疗不良事件报告系统

医疗不良事件报告系统的建立和完善是医疗风险监管和医疗质量持续改进的基础和必然趋势。然而．国内医疗不良事件报告系统发展缓慢．尚不健全。目前未见系统报道。随着区域卫生信息化建设的进一步深化．卫生信息共享对于降低医疗风险、提高医疗质量的作用凸显且日益为人们所肯定和接受。在区域卫生信息化环境下构建医疗不良事件报告系统．实现系统的跨越式发展，成为我国医疗卫生事业改革和发展亟待解决的重要问题。本文拟对基于区域卫生信息平台的医疗不良事件报告系统进行探讨。     

挖掘公立医院卫生资源潜力的思考

随着社区医院、私立医院的兴起,公立医院卫生资源利用率普遍降低,浪费比较严重.为了提高公立医院卫生资源利用率,保持我国医疗事业健康发展和高效运营,挖掘公立医院卫生资源潜力势在必行.     

卫生医疗与社会经济发展的关系浅析

卫生医疗是社会经济的重要组成部分。它既隶属于社会经济系统，社会经济发展水平、体制决定卫生医疗发展方向和运行模式，它的发展又对社会经济发展具有重要的促进作用。贯彻科学发展观，“以人为本”就必须将卫生医疗置于重要社会地位上，确定正确的卫生医疗发展的方向与模式，促进卫生医疗发展和增进人类健康始终是我国现代化发展的重要内容。     

社会资本投资于医疗服务领域的相关政策探讨

我国从计划经济向市场经济转轨过程中，社会、经济、人口和疾病模式发生了显著变化，逐步出现了医疗服务市场；20世纪90年代中期以前，卫生改革围绕“放权搞活、提高服务能力”，逐步解决了“看病难”等问题。90年代后期以来，改革重点是调整卫生服务体系、提高卫生资源的合理配置和卫生服务绩效。在过去的25年中，我国医疗服务市场日益多元化，竞争更加激烈复杂，对卫生改革政策提出了更高要求。近年来，进一步开放医疗服务市场，完善医疗服务体系成为卫生改革的重点。     

优化区域卫生规划 夯实合理配置医院基础

区域卫生规划是政府对区域内卫生资源合理配置、有效利用和对卫生发展宏观调控的重要手段。其作用是通过提高资源的配置效率，保证城乡居民公平地获得基本医疗，满足多层次的卫生服务需求，解决“看病难”问题，实现医疗服务的公平性。     

健康医疗大数据国内外发展及在卫生决策支持中的应用展望

介绍了美国、英国、日本等主要发达国家的健康医疗大数据建设发展现况,回顾了我国健康医疗大数据建设和应用的现状。提出健康大数据可在深化医药卫生体制改革评估监测、医疗服务能力评价、医院风险监控管理、医疗资源优化配置等方面挖掘和研究,以加强健康医疗大数据在卫生决策支持中的应用。     

北京诊断相关组的分组过程和方法

诊断相关组在多个国家和地区广泛应用.不同国家和地区使用的DRGs都是与本土具体环境相适应的版本.北京诊断相关组(BJ-DRGs)是中国首个根据本地信息和政策环境而独立开发的DRGs系统.本文从BJ-DRGs分组原则、逻辑、方法等方面简要地介绍了BJ-DRGs划分和组合病例的技术问题,并以“耳鼻咽喉类疾病”为例,展示了BJ-DRGs的分组过程.     

DRGs改革背景下临床路径效用分析

DRGs是继临床路径后的又一项医改内容,是目前世界范围内推行的医保支付方式之一,正逐步在我国应用推广。对六盘水市某医院DRGs付费试点工作前后的临床路径相关指标进行3年的对比分析(入径人数、完成人数、平均住院日、平均医疗费用等),分析DRGs对临床路径的应用带来的积极效用:一方面DRGs为临床路径的推广起了促进作用,为细化医疗服务和医疗考核指标提供保障,另一方面临床路径作为DRGs深入临床执行的有效基础,两者相互支撑,共同提升医疗质量。预计未来DRGs与临床路径的结合会越来越紧密。     

Severity of illness within DRGs: impact on prospective payment.

This study compares the financial impact of a Diagnosis Related Group (DRG) prospective payment system with that of a Severity of Illness-adjusted DRG prospective payment system. The data base of about 106,000 discharges is from 15 hospitals, all of which had a Health Care Financing Administration (HCFA) DRG case mix index greater than 1. In order to pool the data over the 15 hospitals, all charges were converted to costs, normalized to Fiscal Year 1983, and adjusted for medical education and wage levels. The findings showed that, for the study population as a whole, DRGs explained 28 per cent of the variability in resource use per case while Severity of Illness-adjusted DRGs explained 61 per cent of the variability in resource use per case. When we simulated prospective payment systems based on DRGs and on Severity-adjusted DRGs, we found that the financial impact of the two systems differed by very little in some hospitals and by as much as 35 per cent of total operating costs in other hospitals. Thus, even with a data set that is relatively homogeneous (with respect to the HCFA DRG case mix index definition of hospitals), we found substantial inequities in payment when DRGs were not adjusted for Severity of Illness. These findings suggest that, with a more representative set of hospitals, the difference between unadjusted and Severity-adjusted DRG-based prospective payment could be greater than 35 per cent of a hospital's total operating costs.     

Cost-variance analysis by DRGs; a technique for clinical budget analysis

In this article it is shown how a cost accounting system based on DRGs can be valuable in determining changes in clinical practice and explaining alterations in expenditure patterns from one period to another. A cost-variance analysis is performed using data from the orthopedic department from the fiscal years 1993 and 1994. Differences between predicted and observed cost for medical care, such as diagnostic procedures, therapeutic procedures and nursing care are analyzed into different components: changes in patient volume, case-mix differences, changes in resource use and variations in cost per procedure. Using a DRG cost accounting system proved to be a useful technique for clinical budget analysis. Results may stimulate discussions between hospital managers and medical professionals to explain cost variations integrating medical and economic aspects of clinical health care.     

两种DRGs指标体系的绩效评价效果比较研究

目的应用传统与新型DRGs指标体系进行绩效评价效果比较研究,探讨新型DRGs指标体系应用价值。方法基于某省大数据平台的31家三级综合公立医院DRGs资料,分别采用传统与新型DRGs指标体系对之进行综合绩效评价,采用Pearson检验对医院排名进行相关性分析,通过专家咨询法论证两种指标体系。结果31家医院排名均发生了变化,超过一半的医院排名变化幅度超过10名。两种DRGs指标体系的医院排名不存在显著相关性（相关系数为-0.348,P=0.057）,即在实际评价效果上存在较大差异。新型DRGs评价指标体系的应用价值优于传统型。结论相较于传统DRGs指标体系,新型DRGs指标体系严格把控区域医疗质量指标,通过强化学科评价与费用控制,重视患者医疗质量,使评价更为科学、全面。     

New ways of financing and organizing health care in Sweden

The health care system in Sweden has been undergoing radical change since 1991. The mainly public financed (90%) system with 26 autonomous counties spent 8.5% of its gross domestic product on health care in 1991. The main features of the 'paradigm shift' are: separation of production and financing; resource allocation to health districts in relation to the needs of the population; and introduction of public competition between health districts (purchasers) and hospitals (providers). The health district boards are responsible for the health care of the population in their district hospitals financed by their activities (e.g. through diagnosis-related groups (DRGs)) and quality aspects monitored by central authorities. A parliamentary committee (HSU 2000) is investigating how Sweden's health care system can be organized and financed in the future. Three models are analyzed: a reformed county council court model, a primary care-managed model, and a compulsory insurance model. Each model must be consistent with equity and public financing. From 1992 in the Stockholm county, five surgical specialties were paid for their activities according to DRGs for inpatient care and another system for outpatient care. The number of treated patients during 1992 increased by 8% in inpatient care, 50% in day surgery and by 15% in outpatient care. Taken together, the activities increased by 11%, which is slightly more than the expected 10% increase in productivity. (There was a 10% decrease in DRG prices from 1 January 1992.) The total costs decreased by 1% due to fewer personnel. Nothing has been reported concerning the quality of care, neither before nor after the model was introduced. From 1993, all somatic acute specialties are paid by DRGs and the equivalent outpatient classification systems. The results from 1993 will be presented in the autumn of 1994.     

我国医疗联合体建设现状与发展思考

医疗联合体是我国建设整合型医疗卫生服务体系的具体表现形式之一,具有优化资源配置、提高资源利用率、改善不合理就医秩序、促进医疗机构同质化发展的重要作用。通过梳理医疗联合体构建背景、发展历程、国内外典型经验,结合党的十九届五中全会精神,为完善我国医疗卫生服务体系,提出要构建科学、有效、统一的医疗联合体绩效考核评价体系,充分发挥绩效评估的激励引导作用,开展医疗联合体评估工作,推动医疗联合体高质量发展。     

某医院新农合按病种付费实施情况探析

2011年,北京市率先在全国启动按病种付费试点改革,随后该支付方式被推向全国。实施按病种付费确实有利于减轻新农合患者的医疗经济负担,但具体的政策执行却需要医疗机构的积极配合和落实。通过对某三甲医院新农合按病种付费方式实施情况的研究,了解医疗机构在实际执行按病种付费制度中取得的成效及存在问题,为合理改善医院新农合按病种付费管理工作提供依据。     

Kodieren von Krankenhausleistungen allgemein und speziell bei Malignomen und HIV/AIDS

The new DRGs reimbursement system will start as an optional model in 2003.The compulsory introduction of this new system will take place on 1 January 2004.The reimbursement system based on diagnosis-related groups (DRGs) is supposed to be implemented within 4 or 5 years. In order to guarantee a performance-oriented reimbursement, comparable cases will be assigned to the same DRGs.This can only be achieved if diagnosis and classification procedures are standardized.The general and special German DKRs regulate and support this process. The structured classification of diseases is guaranteed by ICD-10-SGB V.Thus, standardization of diagnoses according to an internationally accepted system recommended by WHO will be achieved.Moreover, further developments in medical progress and adjustments for costs will be taken into consideration to advance clinical performance. A far-reaching general structural change in health care will take place and will not be restricted to hospitalized patients. It is absolutely necessary that the DRGs be adapted to the German standards in order to guarantee a highly economic and efficient health service.The growing bureaucracy in medicine should not prevent doctors from their responsibilities towards their patients.     

美国诊断相关组的引进

诊断相关组是美国医疗保险医院补偿系统预付费的依据,目的是将医院的病例组合与所需的资源和花费相联系.各组的定义与划分应有共同的组织系统或病因学,且有共同的临床特性又有相近的资源消耗.根据主要诊断、主要手术、重要的合并症和并发症、年龄(以17岁区别成年人和未成年人)、性别、新生儿体重等进行分组.按照美国第18版分组定义编制程序,对北京二级以上医院病案首页数据进行分组,根据分组情况、分组的合理性及各组的权重分析,采用美国的分组结构是可行的,但应根据我国情况进行适当的变更.