不同医疗卫生机构的基本医疗保险支付方式选择模式探究

基于不同基本医疗保险支付方式的利弊分析、借鉴国外典型国家基本医疗保险支付方式,结合国内医疗卫生机构基本医疗保险支付方式的成功经验,探究不同医疗卫生机构的基本医疗保险支付方式选择模式。建议针对基层医疗卫生服务机构,采用总额预付制或按人头付费为主的方式;针对二级、三级综合医院,采用总额预付制为基础的,按病种付费为主,结合按人头付费、按服务项目付费和按床日付费等支付方式的医保支付模式;专科医院,采用总额控制下按病种付费和按床日付费相结合的支付模式。     

两种医疗支付方式博弈理论分析

我国医疗保险支付方式改革的重点之一是将过去的按服务项目付费转变为按病种付费。通过建立两种医疗支付方式下医患、医院与医保局双方的博弈模型,分析了2种支付方式下博弈各方的行为特点。分析表明,按病种付费在控制不合理医疗费用上相较于按服务项目付费更优。不论在哪种支付方式下,优化医保监督管理方式使得监管难度降低的同时,增大处罚力度也是遏制医院不合理医疗的有效途径。     

基于疗效评价探究DIP对医生诊疗行为的影响△

目的： 探索按病种分值付费方式改革对三甲公立医院医生医疗行为的影响，为医院更快、更好适应医保付费模式改革提供建议。方法： 采用问卷调查及回顾性分析方法，对临床医生的医疗行为和看法进行分析。收集分析该院DIP付费改革前（2023年6月）和改革后（7月）带状疱疹病历各50份。结果： 改革前后的异地就医情况、检查费用、药物费用、治疗效果、住院天数等医疗行为无显著差异；问卷调查结果显示临床医生对按病种分值付费改革的认知度与认可度有待加强，需要开展针对性培训。结论： 医保部门应考虑建立复杂病例付费模式；医院应加强编码人员以及临床医疗工作者的相关培训，提升病案质量及填写规范，增强对医保付费改革的认知度与认可度；卫生部门应加强医保支付与医疗行为的监管。     

按病种分值付费下公立医疗机构的管理策略

医疗机构作为按病种分值付费政策的主要执行者,医疗机构应该抓紧机遇,推进按病种分值付费的配套措施,实现高质量发展。笔者从按病种分值付费的政策梳理、按病种分值付费促进医疗机构强化管理的作用机制以及公立医疗机构应对按病种分值付费支付方式所采取的管理策略等方面进行梳理,以期为医疗机构落实按病种分值付费提供借鉴。按病种分值付费下的管理策略涵盖发展规划、组织架构、形成工作闭环、规范诊疗、提升病案质量、加强信息建设等方面。     

DIP关键要素分析及医院管理策略研究

2018年1月1日,广州市医保付费方式由定额结算付费正式转变为按病种分值付费。这种付费方式能够对医疗费用上涨进行有效控制,并且能够对医疗服务中医方、保方与患者三方的关系进行有效调整,最大程度上发挥出有效卫生资源的作用。从保方来说,支付方式的转变,可达到“总盘子不穿洞”的目的,但对院方来说,医院医保管理模式必须从以“量”增收向以“成本”提效转变。2020年广州某三级医院(以下简称A医院)从按病种分值付费的政策及核算规则出发,提炼影响支付方式的关键要素,“抓大放小”,转变了以往亏损严重的情况,达到了扭亏为盈的局面。     

传统DIP向总额控制下的DIP转型分析

芜湖市作为国内较早一批探索按病种分值付费的城市之一,通过多年实践探索出了病种标准、医院系数、特例单议、个人负担控制比例、费用结算、医院互查及沟通协商等一套传统的按病种分值付费体系。为顺应国家医保支付方式改革趋势,文章依据芜湖市经验就如何实现传统按病种分值付费向总额控制下基于大数据的按病种分值付费模式的转变,如何实现“同病同城同保障”,为按病种分值付费与特殊医疗需求的矛盾等问题提出建议。     

DIP付费改革对医疗机构经济运行的影响研究——以广州市某三甲医院为例

以广州市某三甲医院住院数据为例,深入剖析广州市按病种分值付费在划分病种、设定医疗机构权重系数、建立偏差病例调节机制、制定结算办法等核心环节的做法,对比分析医保支付方式改革前后医疗机构服务能力、服务效率、费用控制、质量监管、基金监管等运行指标的变化,从而分析改革的成效和主要挑战,为调整完善按病种分值付费政策提出建议。     

基于临床路径的DIP病种成本管理研究

在按病种分值付费(diagnosis-intervention packet, DIP)支付改革不断发展推进的形势下,医院费用成本管控迎来新挑战。深圳某医院探讨在DIP支付方式改革形式下,结合临床路径和DIP医保支付标准,建立DIP病种临床路径,优化医院医疗服务费用结构,合理使用医保基金,促进医院成本管理转型。     

由后付制向预付制转变对医生行为影响的实验研究

目的:利用经济学实验探究按服务项目付费(FFS)和按疾病诊断相关分组付费(DRG)的激励对医生医疗服务供给行为的影响。方法:利用z-tree软件编程,招募120名临床相关专业的高年级本科生和研究生作为被试,测试其在FFS与DRG下为不同健康状况的患者选择提供的医疗服务数量。结果:总体上受试者在FFS(DRG)下提供的平均医疗服务量高(低)于最优服务量,差异有统计学意义。FFS下,受试者为健康状况好和中等的患者提供的平均医疗服务量分别为5.14、6.15,均高于最优服务量,在DRG下,受试者为健康状况好、中等、差的患者提供的平均医疗服务量分别比最优服务量少2.15%、10.73%、23.40%,差异有统计学意义。结论:FFS激励医生提供过量的医疗服务,DRG激励医生提供不足的医疗服务。FFS下医生对处于好和中等健康状况的患者过度服务,而DRG供给不足的程度随着患者疾病严重程度的增加而增加,且DRG下医生为健康状况好的患者提供的医疗服务量对患者最有利且医生所损失的净收益最少,对于健康状况中等和差的患者则相反。     

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。     

家庭医生签约背景下竞争机制引入对医生行为影响的实验研究

目的：检验支付方式结合竞争“双机制”对医生行为的影响,为家庭医生签约制度的完善提供实验经济学证据。方法：通过受控实验研究,设计非竞争和竞争场景,结合按人头付费(CAP)和按项目付费(FFS)支付方式,开展实验经济学研究。利用随机效应模型分析竞争机制对医疗服务数量和患者健康效益的影响;通过费舍尔组合检验,探讨不同支付方式引入竞争机制对医生行为影响的差异。结果：竞争机制引入后会减少CAP(FFS)支付方式下服务量供给不足(供给过度)的程度。对于健康状况差(好)的患者,竞争机制在CAP(FFS)支付方式下对医生行为改变程度更大。竞争机制组间系数比较显示,相比于FFS,“CAP+竞争机制”患者健康效益损失更少。在竞争转为不竞争场景下医生提供服务量与患者健康效益最优服务量的偏移程度增加。结论：引入竞争机制可以改善家庭医生医疗服务质量,按人头付费结合竞争的双机制设计具有一定的优势。     

医保支付方式由后付制向预付制改革对供方医疗服务行为影响的机制和发展路径

全民医保制度下,支付方式提供了影响供方医疗服务行为的手段,成为调节卫生资源配置的重要杠杆.医保支付方式由后付制向预付制的改革,通过财务风险的转移调整对医疗机构和医生行为的激励,控制供方诱导需求行为带来的费用上涨,成为医疗保险制度改革的重要方向.但其发挥作用的基础是医疗服务提供方对支付方式的反应.医疗服务目标的多维性、医...     

Moving (realistically) from volume-based to value-based health care payment in the USA: starting with medicare payment policy

Employers and policy-makers in the USA are desperate to slow the rate at which health expenditures grow. Changing how most health care providers are reimbursed will be necessary to achieve this. Although both politically and practically daunting, massive restructuring or replacement of fee-for-service (FFS) reimbursement is what is most required. As the dominant reimbursement model in the USA, FFS payment to individual providers strongly encourages and financially rewards the quantity of care provided, regardless of its quality or necessity. Providing high quality, lower cost care with fewer complications and hospital re-admissions can even financial penalize providers. Unfortunately, physicians and other health providers respond rationally to existing financial incentives (translation: they do what they get paid to do and generally try to, or have to, minimize those activities and services for which they are not paid). Altering this reality and fostering the expansion of exemplary delivery models-such as the Mayo Clinic or Geisinger Health System-requires change in how providers behave. And changing behavior often starts with adjusting how providers are paid. Medicare is the programme and payer most capable of using payment reform to catalyze delivery system reform.     

How payment systems affect physicians' provision behaviour--an experimental investigation

Understanding how physicians respond to incentives from payment schemes is a central concern in health economics research. We introduce a controlled laboratory experiment to analyse the influence of incentives from fee-for-service and capitation payments on physicians' supply of medical services. In our experiment, physicians choose quantities of medical services for patients with different states of health. We find that physicians provide significantly more services under fee-for-service than under capitation. Patients are overserved under fee-for-service and underserved under capitation. However, payment incentives are not the only motivation for physicians' quantity choices, as patients' health benefits are of considerable importance as well. We find that patients in need of a high (low) level of medical services receive larger health benefits under fee-for-service (capitation).     

DIP支付方式与紧密型医共体总额付费政策融合研究

在DIP的政策框架范围内,探索DIP支付方式与紧密型医共体总额付费政策融合模式,分析各模式对医共体服务行为影响。本研究应用博弈论从政府和医共体、医共体和医疗机构双层经济激励结构,即外部支付方式和内部分配模式两个层面,构建医共体打包付费三个组合模式下的博弈模型。研究发现,当DIP支付方式既用于外部支付,又用于内部分配时,扩大服务量为最优策略,容易导致医共体内外竞争;当只用于外部支付,不用于内部分配,仍持续对外进行服务扩张,内部分配制度的设计空间不足;当不用于外部支付,只用于内部分配时,有助于通过按人头总额付费削弱医共体对外的无序竞争,同时通过DIP支付规则,应用区域内不同点值规范医疗机构恶意扩大服务量的不合理行为。     

Testing the myth of fee‐for‐service and overprovision in health care

Paying on the basis of fee‐for‐service (FFS) is often associated with a risk of overprovision. Policymakers are therefore increasingly looking to other payment schemes to ensure a more efficient delivery of health care. This study tests whether context plays a role for overprovision under FFS. Using a laboratory experiment involving medical students, we test the extent of overprovision under FFS when the subjects face different fee sizes, patient types, and market conditions. We observe that decreasing the fee size has an effect on overprovision under both market conditions. We also observe that patients who are harmed by excess treatment are at little risk of overprovision. Finally, when subjects face resource constraints but still have an incentive to overprovide high‐profit services, they hesitate to do so, implying that the presence of opportunity costs in terms of reduced benefits to other patients protects against overprovision. Thus, this study provides evidence that the risk of overprovision under FFS depends on fee sizes, patients' health profiles, and market conditions.     

The Effects of Introducing Mixed Payment Systems for Physicians: Experimental Evidence

Mixed payment systems have become a prominent alternative to paying physicians through fee‐for‐service and capitation. While theory shows mixed payment systems to be superior, causal effects on physicians' behavior when introducing mixed systems are not well understood empirically. We systematically analyze the influence of fee‐for‐service, capitation, and mixed payment systems on physicians' service provision. In a controlled laboratory setting, we implement an exogenous variation of the payment method. Medical and non‐medical students in the role of physicians in the lab (N = 213) choose quantities of medical services affecting patients' health outside the lab. Behavioral data reveal significant overprovision of medical services under fee‐for‐service and significant underprovision under capitation, although less than predicted when assuming profit maximization. Introducing mixed payment systems significantly reduces deviations from patient‐optimal treatment. Although medical students tend to be more patient regarding, our results hold for both medical and non‐medical students. Responses to incentive systems can be explained by a behavioral model capturing individual altruism. In particular, we find support that altruism plays a role in service provision and can partially mitigate agency problems, but altruism is heterogeneous in the population. Copyright © 2015 John Wiley & Sons, Ltd.     

Presidential address: Preventive medical practice

Review of national programs in the past decade suggests that there is a developing consensus regarding the need for preventive services, but the proportion of them that physicians provide is decreasing. As teachers of preventive medicine, we should have a particular concern with the physician's performance in providing preventive services. Specialization, practice organizations, and comprehensiveness of payment for medical care appear to be related to the volume of preventive services provided. Organized primary care practice sites, where other health professionals are available, seem especially well-suited to providing preventive services. A review of several effective preventive activities involving physicians (child and adult immunizations, early detection and treatment of PKU infants, and stroke prevention) indicates that current prevention practice is less than desirable. Better performance can be attained through successful national and community programs of consumer and physician education. Implications of these observations for medical undergraduate and graduate education in prevention are discussed.     

Production of physician services under fee‐for‐service and blended fee‐for‐service: Evidence from Ontario,Canada

We examine family physicians' responses to financial incentives for medical services in Ontario, Canada. We use administrative data covering 2003–2008, a period during which family physicians could choose between the traditional fee for service (FFS) and blended FFS known as the Family Health Group (FHG) model. Under FHG, FFS physicians are incentivized to provide comprehensive care and after‐hours services. A two‐stage estimation strategy teases out the impact of switching from FFS to FHG on service production. We account for the selection into FHG using a propensity score matching model, and then we use panel‐data regression models to account for observed and unobserved heterogeneity. Our results reveal that switching from FFS to FHG increases comprehensive care, after‐hours, and nonincentivized services by 3%, 15%, and 4% per annum. We also find that blended FFS physicians provide more services by working additional total days as well as the number of days during holidays and weekends. Our results are robust to a variety of specifications and alternative matching methods. We conclude that switching from FFS to blended FFS improves patients' access to after‐hours care, but the incentive to nudge service production at the intensive margin is somewhat limited.