医保药品支付标准改革对定点医疗机构临床用药的影响——基于福建省省本级、福州市参保人员医疗费用的实证分析

目的:评估福建省医保药品支付标准改革对定点医疗机构临床用药的影响。方法:分析福建省省本级、福州市医疗保险管理中心331万参保人员2016年4~9月及上年同期门诊和住院药品消费数据,按年度统计药品费用、用药情况以及医保药品支付标准政策执行情况。结果:改革前后医保药品支付标准目录内费用占比从22.50%上升为64.95%;公立医院及非公立医院改革前后门诊药品前10位一致仅排序略有变化,改革后两者门诊支付标准内费用占门诊费用比例分别为73.21%、39.30%;公立医院住院前10位药品品种及其金额变化较大,其中联合采购价差较大的药品费用增幅较高,而非公立医院相对稳定。结论:医保药品支付标准改革显著影响了临床用药品牌选择和用药结构;以药品集中采购结合联合带量采购形成的医保药品支付标准有利于降低药品价格;医保药品支付标准改革结合医药卫生体制综合改革措施更有利于发挥引导作用。     

四川省公立医院薪酬制度改革政策系统分析

薪酬改革是公立医院改革重点.本研究运用社会网络分析法以地市为单位,对四川省公立医院薪酬制度改革相关政策进行系统分析发现:四川省公立医院薪酬制度改革启动良好,已进入实质性改革阶段,无论是省级层面、地市州级甚至县级层面均进行了积极响应,目前亟需进一步深化公立医院综合改革,加快相关政策制定、实施步伐,与医疗、医保、医药联动改革相衔接,探索建立适应全省公立医院特点的薪酬制度.     

北京取消药品加成政策对某三甲医院经济运行质量的影响研究

目的:探讨取消药品加成政策对公立医院经济运行质量的影响效应,分析医改政策效应持久性,为全面开展医药分开综合改革政策提供决策参考。方法:采用合成控制法,以2012年北京市试点取消药品加成的市属公立三甲Y医院为处理组,以未取消药品加成的其他市属三甲医院为对照组,分析取消药品加成对医院资产负债率的影响。结果:取消药品加成后,Y医院资产负债率降低,并且通过安慰剂检验证实Y医院资产负债率下降非偶然因素,但长期看,Y医院资产负债率有上涨趋势。结论:取消药品加成政策效应存在递减现象,建议实施改革配套措施以持续巩固政策实施效应。     

北京市医药分开综合改革对门急诊费用控制的机制研究

目的:评价北京市医药分开综合改革对医疗机构门急诊总费用的机制及影响。方法:对北京市89家三级公立医院、78家二级公立医院和206家一级医院与社区卫生服务机构的监测数据和历史数据进行分析,比较2017年一二季度与2016年一二季度门急诊费用的变化,并分析服务利用和服务价格因素对门急诊费用变化的影响机制。结果:2017年二季度监测医疗机构的门急诊总费用为173.77亿元,扣除物价因素后,较2016年同期减少1.14%,费用增速下降2.46%。三级医院和二级医院费用较历史同期水平分别减少了2.82%和3.02%,增速分别下降4.06%和3.74%。基层医疗卫生机构费用较历史同期水平增加17.09%,2017年二季度增速为26.28%,比2016年(15.84%)大幅度提升。医疗机构服务价格和服务利用对门急诊费用变化的贡献分别为6.98%和-7.65%。三级医院价格和利用对门急诊费用控制的贡献分别为10.37%和-12.00%。二级医院价格和利用的贡献分别为0.72%和-3.35%。基层医疗卫生机构的价格和利用对门急诊费用控制的贡献分别为6.08%和9.57%。结论:北京市医药分开综合改革通过调整卫生服务利用,有效控制了门急诊费用的过快增长。     

Provider responses to a global budgeting system: The case of drug expenditures in Taiwan hospitals

In July 2002, a global budgeting system was imposed on hospitals in Taiwan. This system set a fixed budget for all hospitals within a region but included special provisions that sheltered reimbursements for drug expenditures. We study the size and nature of changes in hospital physicians' use of drugs for outpatient care following this budgetary change and find that drug expenditures for outpatient care increased by 11.7%. Our results suggest that physicians began prescribing more expensive drugs, more drugs, and drugs for longer periods but that these different responses did not all occur at the same time. The overall response was strongest in for‐profit hospitals, but drug‐related decisions changed in all hospital types.     

Revolving drug funds at front-line health facilities in Vientiane, Lao PDR

Pharmaceutical cost recovery programmes, which have been mainly implemented in Africa, are gradually spreading to Southeast Asian countries that formerly belonged to the socialist bloc. This report describes the economic and operational realities of revolving drug funds (RDFs) at district hospitals and health centres in the capital of the Lao PDR by reviewing research conducted by the implementing department. People in the municipality spent an average of US$11 on drugs in 1996. The RDFs comprised only 3% of the total yearly drug sales in the municipality, whereas private pharmacies accounted for 75%. The RDFs were forced to operate in conjunction with the remaining government drug endowment and the thriving private pharmacies. This scheme has provided a stable supply of essential drugs. The assurance of drug availability at the front-line health facilities has resulted in increased utilization of the facilities despite the introduction of a drug fee. The cost recovery rate was 107% at health centres and 108% at district hospitals in two monitored districts during the 10 months from November 1997. Decentralized financial management was essential for cost recovery, allowing timely adjustment of selling prices as purchase prices rapidly inflated after the Asian economic crisis. The health staff observed that the people perceived drugs as everyday commodities that they should buy and take based on self-diagnosis and personal preference. Adaptation of the public health authorities to market-oriented thinking along with the establishment of pharmaceutical cost recovery occurred with few problems. However, both financial and operational management capacity at the municipal level pose a major challenge to policy clarification and scheme setting, especially in procurement, control of prescribing practices and the integration of drug dispensing with other components of quality clinical care.     

老年人卫生服务利用情况及影响因素分析

[目的]了解江西省60岁以上人群医疗服务利用情况及其影响因素，为卫生服务管理与决策提供依据。[方法]采用整群抽样，以家庭卫生服务调查表及问卷调查的方式对老年人的一般健康状况及卫生服务利用情况进行调查。[结果]老年人中两周就诊率7.01%，年住院率6.00%。城市老年患者主要选择县区级医院就诊，农村老年患者主要选择私人开业的医疗场所就诊，对社区卫生服务站的利用较低。人均住院费用占人均医疗总费用的79.49%。两周门诊就诊费用和住院费用都主要集中在县级医院和省级医院，占总各费用的81.01%和68.29%。[结论]医疗费用与经济收入成为影响老年人对卫生服务的合理利用的重要因素。完善医疗保障制度，积极开展社区卫生服务是解决老年人医疗保健问题的有效途径。     

基于主成分分析的武汉市公立医院综合评价研究

目的 将武汉市市属医院与部、省属医院进行综合评价并进行对比,以发现武汉市属医院薄弱环节,为当地卫生部门提高市属医院综合效率、提供医院管理决策提供依据.方法 选取10个代表性指标,运用主成分分析对位于武汉市的26家医院(市属和部、省属各13家)进行综合评价.结果 确认了第一主成分为反映医院的医疗服务能力的综合指标,第二主...     

绍兴市市级公立医院综合改革试点的实践与思考

绍兴市在国内较早启动了公立医院改革试点,从取消药品加成入手,由县级到市级医院逐步推进实施,探索提出“一减二调一补”的综合改革方案,从根本上取消了药品加成,破除了“以药养医”机制,为其它地区公立医院改革提供了改革思路。     

医院药品集中采购政策的背景和演变

医院是我国药品的主要销售渠道,且长期以来药品由单个医院分散采购。针对药品生产、流通秩序混乱,药品价格虚高等问题,有关部门从2000年开始在全国推行以地（市）为单位的药品集中招标采购。整个制度演变可分为地方自发探索集中采购（1993--1999年）,全国推行集中招标采购（2000--2004年）,各地探索新的集中采购方式（2005年至今）三个阶段。政策目标则从单一的“规范医疗机构购药行为”扩展为“整顿药品流通秩序、规范药品价格、纠正医药购销的不正之风、降低群众医药费用负担”等多重目标,并将降低药品价格作为首要目标之一。     

Drug Utilization and Costs for Patients with Acute Myocardial Infarction

The study of drug experience of patients with acute myocardial infarction is part of a series studying factors that influence drug utilization in the hospital. The medical care field is more than ever aware of the associations between use of drugs, hospital costs, and quality of care. Aspects of utilization studied included variety, number, route, purpose, and cost of drugs; use of generic names in prescribing; and timing of drug orders during a patient's stay. In some of these aspects large teaching hospitals differ from small hospitals. It is especially striking that timing of drug orders differed between public and voluntary sectors; this was affected by the greater severity of disease and lower survival rate among city hospital patients. Direct costs of the drugs are low, in general, and so make up a small portion of hospital care costs. Each hospital showed a different pattern for principal purposes of medications used.

Future trends in utilization depend on interactions among social, technical, and administrative developments. Equalizing conditions of admission would smooth out contrasts in drug use between public and voluntary hospitals. Staff review of drugs in use could reduce needless variety. Cardiac monitoring devices can set up new patterns for use of intravenous drugs. Hospitals that must account for drugs under public reimbursement schemes could simplify their tasks by applying a group averaging system to most drugs.

     

河北省部分地区医用X射线诊断设备质控检测结果

目的 调查河北省内省、市、县不同类型医院医用诊断X射线机质量控制水平.方法 主要采用Victoreen NEROTMmAx系统、光密度计、亮度仪进行检测.结果 省级医院全部合格,乡镇卫生院均不合格,市县合格率分别为33.3％与44.4％.就主要检测项目透视X线机性能质量合格率为90％,好于摄影X线机的合格率(27.8％).结论 河北省X射线诊断设备质量控制方面存在问题较多,必须加强质量控制检测的监督力度.     

Addressing government and market failures with payment incentives: Hospital reimbursement reform in Hainan, China

This paper examines the role of provider payment policy as an instrument for addressing government and market failures and controlling costs in the health sector, particularly in developing countries. We empirically evaluate the impact of provider payment reform in Hainan province, China, on expenditures for different categories of services that had been subject to distorted prices under fee-for-service. Using a pre-post study design with a control group, we analyze two years of claims data to assess the impact of a January 1997 change to prospective payment for a sub-sample of the hospitals. This difference-in-difference empirical strategy allows us to isolate the supply-side payment reform effects from demand-side policy interventions. We find that prepayment is associated with a slower increase in spending on expensive drugs and high technology services, compared to fee-for-service. The fact that payment reform is associated with reduced growth in spending on the most expensive drugs is particularly encouraging, given that drugs account for a remarkably high percentage of both the level and growth of aggregate health expenditure in China. Payment reform can be an effective policy instrument for correcting market failures and adverse side effects of government health sector interventions (such as distorted prices to assure access to basic services), both of which can lead to excessive health care expenditure growth. Such health spending growth can have a particularly high opportunity cost for developing countries.     

2009年乌鲁木齐市患者对医药卫生行政管理体制改革的意见调查

[目的]从医药体制实施范围和对象等方面,了解患者对医药卫生行政管理体制的满意度及对相关方面的看法,为进一步推进改革提供参考。[方法]2009年,在乌鲁木齐市新疆医科大学6所附属医院,抽取门诊病人进行调查。[结果]发放问卷330份,收回有效问卷300份,对目前医院医药体制表示满意的占8.33%,认为目前医药卫生体制存在体系混乱的占68.33%,医院垄断的占59.67%,医德降低的占41.00%,不同地区药价不同的占45.00%,医保与非医保药价有差异的占34.67%;看病时遇到的较大困难认为医疗水平低的占43.00%,没有使用医保的占51.33%,费用高的占93.33%,用药多的占47.33%;认为药价普遍高的原因是政府监管不够占81.67%,药品流通环节太多的占75.33%,医院抬高药价的占89.33%,药品采购欠缺透明度的占71.00%,医生人为选用高价药的占94.33%。[结论]患者对目前医院医药体制的满意度很低,由于患者的基本情况不同,他们对目前医院医药体制的看法存在差异。     

广东省省市级综合医院最优规模实证研究

目的测量广东省省市级综合性医院最优规模,对比分析国外情况,分析差异产生的原因。方法应用适存分析法,数据为1995年～2004年10年间广东省省市级综合医院的医院数量百分比和医院产出百分比。结果规模超过700张病床的医院显示出规模经济。随着医院规模越来越大,规模经济的作用更加明显。结果与国外显著不同。结论最优规模对医院与社会有不同含义。我国医院持续扩大规模的原因,可能来自于人口多带来的医疗市场规模扩大和缺乏有效的医疗费用支付机制。两种原因对卫生政策有不同涵义,建议做进一步研究。     

公立医院绩效评价对医院内部绩效管理变革的影响研究——基于京沪案例比较

目的:探索公立医院绩效评价政策对医院内部绩效管理变革的影响及其路径。方法:通过京沪案例比较,从异中求同的角度比较京沪公立医院绩效评价政策变迁及两地市属(级)公立医院内部绩效管理变革的异同点,分析公立医院绩效评价对医院内部绩效管理变革的影响。通过医院案例分析,基于扎根案例医院的总结,分析公立医院绩效评价政策影响医院内部绩效管理变革的路径。结果:京沪公立医院绩效评价政策及其变迁均在一定程度上促进市属(级)医院内部绩效管理在相应内容上的变革,提出以政府主管部门、公立医院、部门科室三层级为核心的影响路径。结论:公立医院绩效评价政策能影响医院内部绩效变革,分析影响路径、制定配套措施有利于促进政策目标的实现。     

南京市属公立医院医药价格综合改革补偿效果评价

目的:分析南京市城市公立医院医药价格综合改革后各医院药品收支、医疗服务收入变化,评价补偿效果,探索差异化补偿方案,为建立动态调整的补偿机制提供依据。方法:选择市属参改医院共10家,收集改革前48个月(2011.11—2015.10)及改革后12个月(2015.11—2016.10)财务收支数据,采用简单线性间断时间序列模型对药品收支差率、取消药品加成损失、医疗服务收入增长率、财政补偿率、医疗服务收入补偿率、综合补偿率进行分析。结果:改革后平均药品收支差率净下降14.24个百分点,医疗服务收入净增长24.29%;药占比平均从42.7%下降到36.9%,医疗服务占比从26.1%上升到30.3%。补偿上,净财政补偿率平均为20.43%、净服务补偿率平均为87.34%,达到政策目标,但净服务补偿率从-21.92%到712.52%不等、净综合补偿率从28.87%到712.52%不等,差异较大。其中,服务补偿率与改革前医疗服务收入占比显著正相关。结论:南京价改在取消药品加成和"80%服务+20%财政"补偿效果上政策目标基本实现,但各医院之间差异较大,服务依赖型医院补偿率超过400%,药品依赖型不到30%,而综合性医院因医疗收入结构和经营效率不同,从50%到100%不等。建议:进一步落实调价范围和调价力度,按年建立动态且差异化的补偿机制。     

Cost containment and health care reform: a study of the European Union

This article gives a short summary of the organisation and financing of health services of the 12 Member States of the European Union. It then describes the latest developments in cost containment in each of the countries. The third section describes the new initiatives for reform in Spain, Italy, the Netherlands, Portugal and the United Kingdom. Finally, it gives a summary of the cost containment measures in the 12 countries, listing them under a set of headings. They are classified as budget control, alternatives to hospital care, cost sharing, influencing authorizing behaviour and limits on supply. The article shows the considerable convergence of policies which is developing. Overall budget control in some form is to be found in 8 of the countries. Where providers are paid by a number of different insurers, budgets are nevertheless applied to hospitals in three countries and in another only to public hospitals. Both Germany and France have used budgets to control other items of expenditure. Profits or the prices of drug companies are controlled in 8 countries and in one indirectly. Three have adopted reference price systems for drugs and another has taken powers to do so. Two have adopted or are moving towards provider markets.