农村合作医疗基金的风险与规避

农村合作医疗制度从卫生经济学的角度看,就是为农村居民提供卫生服务而筹措和分配资金的一个系统,不仅涉及到筹资,而且还涉及资金的管理和分配的各个方面,具有十分丰富的内涵。正因为合作医疗制度是一项复杂的社会保障系统工程,所以,其建立与完善才如此艰难。近几年,尽管把它提到“德政”、“民心工程”的高度,但据有关资料表明,至1997年底我国实行合作医疗的县(市、区)只有10％左右。笔者认为,合作医疗基金风险的存在是影响合作医疗制度建立的重要原因之一。本文仅就农村合作医疗基金的风险与规避作粗浅探讨,旨在抛砖     

浅论新型农村合作医疗基金的管理

宁阳县作为山东省推行新型农村合作医疗工作的试点县之一，自2004年6月1日启动以来，全县参合农民51．8万人，参合率达85．2％，通过近一年的新型农村合作医疗试点工作，我们认为要想始终保持新型农村合作医疗制度持续、稳定、健康发展，得到老百姓的欢迎和拥护，最主要的一点是加强新型农村合作医疗基金管理、保证新型农村合作医疗基金全部用于当地人民群众的医药费报销。     

新型农村合作医疗基金风险来源

为了促进新型农村合作医疗(新农合)的可持续发展,本文从内部风险、外部风险和医疗价格上涨的角度,分析了新农合基金在实际的操作过程中所面临的风险。研究发现,新农合基金的外部风险包括人口老龄化和高龄化、疾病谱的改变、农村居民医疗服务需求的释放等。基金的内部风险则包括筹资风险、道德风险和政策风险、信息化程度有限等。并据此从新农合立法、新农合基金信息化管理、完善筹资机制和加强农村居民宣传教育等方面提出控制新农合基金风险的措施。     

武汉市新型农村合作医疗定点医疗机构门诊服务行为调查分析

目的调查武汉市新型农村合作医疗定点医疗机构门诊服务行为．对服务行为进行评价。方法采用调查评估表．对2007年度武汉市（区）级及乡镇级新型农村合作医疗定点医疗机构门诊治疗、费用及病人满意度进行调查评价。结果区级医疗机构的门诊次均处方费用为56．60元，其中药品费用约占处方费用的85．4％，基本药品费用占79．7％。乡镇级处方费用为35．80元，其中药品费用约占83．4％，基本药品费用占94．6％。参合人群的基本药物、通用药名、抗生素使用比例好于非参合人群．病人对就诊整体满意度较高。结论武汉市新型农村合作医疗定点医疗机构总体运行平稳，基本药品费用占处方费用比例达到较理想水平．对病人的关怀情况比较到位，但还存在着乡镇级医疗机构的例均门诊费用过高、抗生素使用比例过大等问题．需在今后的工作中加以解决。     

化解新型农村合作医疗三大风险

“政府组织引导，职能部门监督管理，中国人寿保险公司承办医疗补助金支付业务，定点医疗机构提供医疗服务”。     

武汉市新型农村合作医疗定点医疗机构住院服务行为调查分析

2003年底，武汉市选择洪山、汉南和蔡甸三个区，开展新型农村合作医疗（以下简称新农合）试点，目前已提前2年实现了制度的全覆盖，参合人数由2004年的33．7万人增加到2007年的244万人，资金筹集水平从2004年人均35元提高到2007年的85元以上。     

切实加强新型农村合作医疗试点工作

农村合作医疗工作实在是太重要了，要做好这项工作需要付出巨大的努力。因此，要切实加强农村合作医疗试点工作。     

太仓市建立市级合作医疗大病风险基金的实践

《中共中央关于建立社会主义市场经济体制若干问题的决定》提出“发展和完善农村合作医疗制度”。根据中央《决定》，我市人民政府在１９９６年以太政７８号文下发了《关于建立健全市农村合作医疗大病风险基金的通知》（以下简称《通知》），并从１９９６年起实施，现将两...     

新型农村合作医疗定点医疗机构不规范行为现况研究

[目的]分析不规范行为的分布,为加强新农合定点医疗机构监管提供决策依据与参考。[方法]按病种抽查样本县(市)、乡级定点医疗机构住院参合与非参合病例,判断与分析存在的不规范行为。[结果]不规范行为中用药过度与自立项目收费占抽查病例数的56%;参合病例收费不规范行为多于非参合病例;县级医院病例用药不规范与收费不规范行为高于乡级医院。[结论]不规范行为中以用药过度与自立项目收费最多见,定点医疗机构的不规范行为因就诊对象、主体不同而有一定差别。     

Incentives and the management of physician behavior in health service organizations

The performance of a health services organization is affected by the cumulative behavior of physicians out of proportion to their numbers or the economic value of their services. Managers are challenged to optimize physician behavior and to change it in concert with the evolving expectations of health service customers. Incentives are the tools available for this effort. This article discusses the interrelation of physician behavior, physician needs, and the major classes of incentives: economic, noneconomic, and rules. While most organizations recognize and use financial incentives, few utilize noneconomic incentives systematically. Given the financial restrictions of advanced markets, managers should understand the role of rules and the value of noneconomic issues to physicians when developing incentive programs.     

Alternative geographic adjustments in Medicare payment to health maintenance organizations

The payment received by a health maintenance organization (HMO) for its Medicare enrollees is proportionate to the average cost of Medicare beneficiaries in that county. However, HMO market share in an area appears to decrease costs in the fee-for-service sector, so that HMOs are paid less. For this and other reasons, alternative payment formulas may be desirable and several are developed in this article. The conceptually simplest location factor would be an input price index. An alternative strategy would also recognize systematic variation in utilization. Utilization rate is regressed on variables such as county population density and physicians per 1,000 persons. The predicted utilization rate times an input price index could serve as a location factor. The value of alternative location factors are presented for specific counties.     

卫生事业单位如何适应国库集中支付制度改革

国库集中支付制度是我国财政制度“三大改革”（政府采购制度、国库单一账户制度、部门预算制度）之一,通过试点于2004年在事业单位全面推行。所谓国库集中支付制度,就是将所有政策性财政资金全部集中到国库单一账户,原则上所有财政支出均由国库直接支付,零星开支由国库授权支付,事业单位的银行账户余额始终为零,因此也称作零余额账户。发展到现在,已将事业单位原来的基本存款账户和零余额账户合并成一个账户。为配合财政制度的三大改革,又陆续推出了人员基础库、专项项目库、工资直发、公务卡等形式。     

Offering-level strategy formulation in health service organizations

One of six different strategies must be selected for a health service offering to provide consumers with distinctive value and achieve sustainable competitive advantage in a market or market segment. Decisions must be made regarding objectives sought, market segmentation, market scope, and the customer-value proposition that will be pursued.     

Recovery of recurrent health service costs through provincial health funds in Cameroon

This article describes the Provincial Health Funds pioneered in two Provinces of Cameroon. These funds are non-profit associations and financed by the community through drug fees and—to a lesser extent—through fees for services. The financial objective of the Funds is the full coverage of both the costs of the drug supply and the recurrent non-salary costs of the entire public health services in the province. In addition the funds are channels for community participation in the management and improvement of health services. Following a discussion of the institutional and legal framework, the paper examines the cost recovery targets and the mark-up necessary to achieve them. Comparison is made with mark-up and prices of private for-profit pharmacies. In its third year of operation, the Fund currently covers 62% of recurrent health service costs, up from 22% in the first year. With increasing number of health centers joining the fund full coverage of recurrent costs is projected to occur at the earlies in year four of operations. The authors argue that the appropriate role of donor assistance is not only to finance investment but also to subsidize recurrent costs, until the fund has reached its optimal anticipated size, thus realizing economies of scale. While the final word on sustainability can only be said years after the funds have reached their final size, the consistent trend towards full cost recovery is encouraging.     

新型合作医疗实施后农村卫生机构服务效率的变化

目的：通过对某省三个新型农村合作医疗（以下简称“新农合”）试点县3所县医院和7所乡镇卫生院的研究,比较在新农合实施前后服务能力和效率的变化情况,探讨新农合对农村卫生服务机构服务效率的影响。结果：新农合实施后县医院和乡镇卫生院的总体服务能力和服务效率均有不同程度的提高,即门诊和住院服务总量增加,每职工（或医生）年负担门诊和住院人次提高。乡镇卫生院次均费用有所提高,但服务效率仍处于较低水平。建议：新农合工作要与农村卫生服务体系建设相结合,逐步完善农村三级医疗保健网的建设。同时,农村卫生机构要更新观念,提高服务效率,降低服务成本,积极支持新农合制度的发展。     

新疆新型农村合作医疗组织机构设置与基金运行管理模式的探讨

国家政策规定,到2 0 10年,实现在全国建立基本覆盖农村居民的新型农村合作医疗制度的目标,新疆地区必须建立新疆新型合作医疗制度。我们依据新型农村合作医疗政策文件要求、文献资料的查阅、结合新疆农村实际情况,研讨提出新疆新型农村合作医疗组织机构设置和基金运行管理模式。1　资料与方法1.1　资料来源　《中共中央、国务院关于进一步加强农村卫生工作的决定》(中发[2 0 0 2 ]13号)和《国务院办公厅转发卫生部等部门关于建立新型农村合作医疗制度的意见的通知》(国办发[2 0 0 3]3号)文件以及《新型农村合作医疗培训讲义(试用)》(2 0 0 3…     

Changing patterns in mental health service coverage within health maintenance organizations

This 1982 national survey of all operational health maintenance organizations (HMOs) provides information on the current status of mental health services, benefits, costs, and utilization within HMOs, updating and augmenting a 1978 study. Approximately 94 per cent of the responding HMOs offered mental health service coverage; over one-half (54 per cent) offered alcohol and drug abuse service coverage. The present coverage benefits and utilization of mental health services within HMOs continue to reflect greater variability vis-a-vis other health services within HMOs. Over one-half (57 per cent) of the HMOs provided for 30 days of inpatient mental health coverage (per member per year). Three out of four (77 per cent) of the health plans provided for 20 ambulatory visits (per member per year). The mean mental health hospital utilization rate was 32 days (per 1,000 members per year). The mean mental health ambulatory utilization rate was 0.33 encounters (per member per year). Further studies should investigate the combined influence of organization characteristics, mental health service organization characteristics, and service benefits on the costs and utilization of HMO mental health services.     

重新构建村级卫生组织 健全网底功能

《中共中央、国务院关于进一步加强农村卫生工作的决定》中提出了“村卫生室承担卫生行政部门赋予的预防保健任务 ,提供常见伤、病的初级诊治”。村级卫生组织这一功能的重要性 ,在这次抗击 SARS的过程中得到了充分的显示。在村级卫生组织健全的地区 ,整个工作开展得井然有序 ,而那些村级卫生组织完全由私人诊所取代的地区 ,则近于一盘散沙。实践证明了重新构建村级卫生组织 ,健全网底功能 ,是农村卫生中一项迫在眉睫的基础工作。1　从“赤脚医生”到“个体行医”,乡村医生已经今非昔比说到村级卫生组织 ,就不能不涉及到对“乡村医生”这…