有限性财政支持和负责任的选择:福利国家后的卫生保健

福利国家在医疗保健的金融资助上片面追求公平、公正、平等。坚持医疗保健享有权的公平、公正、平等虽然符合世俗道德,但不符合情理和伦理学要求,并且会误导政府制定出财政上无法持续、医疗经费支付不合理的保健政策,把医疗保健作为福利来对待从而加重国家和个人的经济负担,而不能全面保障国民的保健需求。从国家政策和个人的选择、医疗保健项目与自我使用的权利和可利用的资源、享有权与道德风险、享有权与政治风险、国家福利制度与制药企业间、医疗技术的进步与医疗成本、医学进步与老年人口增长七个方面全方位探讨医疗保健与人的状况的有限性的关系。建议:发展中国家应该审慎研究发达国家的医疗保健政策,但绝不能照搬;他们需要建立和制定符合自己国情的医疗保障体系和政策,使国民享有全面的医疗保障;为了保障医疗财政支持的可持续性及全面保障国民的保健需求,应建立健康储蓄账户,并以强制性购买灾难性健康保险作为补充,对于一些贫穷的地方或地区,由国家支付经费为其建立健康储蓄账户,形成以家庭为单位的医疗经费支付单位,这样可以避免医疗保健享有权的五大危害:过度消费、政治风险、资源不足的风险、风险转移、哲学风险。     

塑造2006年美国管理式医疗

管理式医疗保健市场正在持续走向逐步扩大的趋势,雇主和政府机构努力驾驭着正在呈现螺旋式上升的医疗费用成本.老龄人口的增加以及更多高成本医疗技术的出现,将促使更深层的卫生服务计划与服务提供者的整合,以及更多创新性的工作,从而让消费者意识到治疗成本与质量的选择.管理保健组织将在未来几个月中感到这些关键性的步骤所带来的巨大变化.     

依托区域中心医院兴办社区卫生服务对建立二级医疗机制的实践与思考

发展社区卫生服务是城市卫生工作的重要组成部分,构建以社区卫生服务为基础,形成社区卫生服务机构和预防保健机构分工合理、协作密切的新型城市卫生服务体系,对于坚持预防为主、防治结合的方针,优化城市卫生服务结构,方便群众就医,减轻费用负担,建立和谐医患关系,已经是医疗卫生服务改革发展的共识.自1996年来到国务院十号文件的发布,使得社区卫生服务的可持续发展进入新的重要时期[1].     

澳大利亚卫生保健概况

澳大利亚的公共卫生事业是两种体制的结合：即私人开业医生提供初级和专门性的保健服务,公立 (由国家管理 )医院和私立医院系统则提供全面的医疗服务。目前澳大利亚还在发展更多样化的医疗保健和社区卫生保健服务,其中包括医疗保健站和家庭保健服务。全国性的妇女保健计划以及防治乳腺癌和子宫颈癌项目的费用由各州和地区政府共同负担。 澳大利亚全国卫生保险计划,即医疗保健计划的目的是使澳大利亚居民住院 (自费病人除外 )、治疗和验光检查都得到保证, 1984年 2月开始实施,部分经费来自对应纳税收入征收 1.4％,低收入者酌情减免。根…     

日本医疗保健制度(下)

现代日本开始进入卫生消费过度增长和经济上巨大压力时期。日本医疗保健制度面临着极其严重的挑战:医疗费用急剧上升:新毕业医生人数的不断增加;平均39天的长期住院日和发生频繁的大处方等。同时日本人口急趋老化,使日本将遇到医疗和社会服务的巨大需求并对传统医疗保健制度是一次严峻地考验。日本人1986年医疗费用总额为17.07万亿日元(1000亿美元),比1985年     

澳大利亚卫生体系及延伸保健模式的启示

澳大利亚有 190 0万人口 ,是世界上全民保健覆盖面最大、保健服务效果较好的国家之一 ,在世界卫生组织 2 0 0 0年对 191个国家调查中其卫生成就、水平和分布排在第 2位 ,其中卫生系统资金提供公正性指数排第 2 6位 (中国第 188位 )。澳大利亚的医疗体制是公、私立并存互补 ,国家实行全民健康保险 ,公共卫生和医疗服务的筹资渠道主要来源于政府 ,少部分来自于私立保险。有支付能力的人可以另外购买私立保险 ,享受更方便快捷和高质量的医疗卫生服务。澳大利亚自 1978年建立并不断改进完善的医疗保险制度 ,称之为“医疗照顾 (medicare)” ,保证…     

全科医学教育的实践

80年代以来，全球范围的医疗卫生事业面临着巨大的转折。突出地表现在人民卫生服务需求的质和量得到普遍提高的同时，医疗费用急剧上涨，超出了国民经济增长率和人民群众的承受能力。变革的出路在于：在更合理地使用卫生资源，有效地预防疾病和保证医疗服务质量的基础上，实现有效的费用控制。从这点出发，发展全科医学，建立起适合我国国情的医疗保健体系，解决好农村和广大基层居民的医疗、预防、保健问题，对最终实现“2000年人人享有卫生保健”的全球战略目标有着重要意义。我校从1986年以来，在探索培养县以下农村卫生机构所需要的医疗…     

私立社区卫生机构的公共卫生功能实现状况分析

目的调查温州市城区不同体制社区卫生服务机构各项卫生功能完成状况,分析私立社区卫生服务机构完成公共卫生功能的动机及其产生的作用,为卫生行政部门提出政策建议。方法采取分层随机抽样方法,对温州市11个不同体制的社区卫生服务中心进行问卷调查。结果私立社区卫生机构实现了大量的公共卫生功能,却没有得到政府补偿。建议在卫生行政部门监管下,政府应根据提供服务的质和量,以统一的标准考核,给予不同体制社区卫生服务机构开展的基本公共卫生服务项目以相应费用补偿。     

关于召开“构建中国生命伦理学与深化卫生改革”国际学术会议的征文通知

为了构建中国生命伦理学,和谐医患关系,深化卫生改革,促进卫生事业的可持续发展,由西安交通大学医学院与香港浸会大学应用伦理学研究中心共同发起和主办,并由中国医学伦理学杂志(西安)、中外医学哲学杂志(香港)、医学与哲学杂志(美国,SSCI收录)及医疗保健委员会论坛杂志(美国)协办,召开构建中国生命伦理学与深化卫生改革国际学术会议。会议将于2009年11月1-3日在西安召开。会议征文题目:(1)中国生命伦理学的构建;(2)中国传统生命伦理学的精华及现代意义;(3)儒家伦理与生命伦理学;(4)儒家伦理对卫生改革的启示;(5)道德哲学与生命伦理学;(6)深化卫生改革的理论体系与实践方略或经验总结;(7)建立和谐医患关系的理论体系与实践方略或经验总结;(8)政府在构建生命伦理学与深化卫生改革中的职能;(9)社会公众及新闻媒体在构建生命伦理学与深化卫生改革中的职能;(10)医学院校、医药行业及医务人员在构建生命伦理学与深化卫生改革中职能;(11)政府领导、卫生管理人员尤其医院院长、制药企业的负责人在构建生命伦理学与深化卫生改革的职能;(12)学会、伦理委员会的自身建设及其在构建生命伦理学与深化卫生改革的职能;(13)在医疗...     

云南省新型农村合作医疗现状探析

云南省新型农村医疗制度全覆盖顺利开展,但在资金筹资、使用和管理等方面存在着如筹资成本高、补偿方案不完善、卫生服务机构服务水平不高、医疗费用上涨较快、管理机构工作人员能力和管理水平有待提高等一些亟待研究解决的问题。本文提出建立稳定增长的筹资机制;制定和完善合理的补偿机制;提高卫生服务水平和能力;积极控制费用使农民利益最大化;建立有效的管理机制等建议,推进新型农村合作医疗制度的可持续发展。     

Polls point to growing gap between MDs, patients over financing of health care

An unprecedented round of CMA polling points to some startling differences in the way physicians and patients perceive the financial problems facing Canada's health care system. One poll indicates that doctors consider recent federal budget cuts a sign that the private sector will soon have a major role to play in health care financing. However, a poll of nonphysicians shows that Canadians oppose any move toward “out-of-pocket” payments for health care services, including payments for private insurance. The CMA board has responded by turning much of the 1995 annual meeting over to the topic of the future of health care in Canada, including financing, and the medical profession's response.     

A better idea for United States health care--the balanced choice proposal

This article introduces a promising new health care financing proposal for physician payment called Balanced Choice. It summarizes the implications of health care economics and current well-publicized health care reform proposals, each of which is problematic for physicians and their patients. The Balanced Choice proposal is for an integrated two-tier national system, which has an economically efficient universal plan similar to single-payer, but with an option for enhanced services using market forces at the doctor-patient level to manage care. The two tiers are linked together and balanced so that each complements and enhances the other. Balanced Choice solves the problems of other proposals in a way that would work well for doctors and for patients, and represents a fresh and uniquely American solution to the problem of health care financing.     

A national health program: northern light at the end of the tunnel

Woolhandler and Himmelstein are members of Physicians for a National Health Policy, a working group that proposes a reform of health care financing in the United States. In this commentary, they describe a national health program (NHP) that would create a single tax-funded comprehensive insurer in each state, federally mandated but locally controlled. The NHP would be similar to the Canadian system of financing health care, which is described here and contrasted with the inflationary, fragmented, bureaucracy-laden system now in place in the United States. Woolhandler and Himmelstein call for a complete overhaul of health care financing in this country that would reduce bureaucratic overhead and intrusion into the physician patient relationship, reduce health care costs, reallocate funds from administration to clinical care, and allow all Americans access to care.     

欧洲卫生筹资模式的改革

基于WHO欧洲委员会"增加财富与增进健康的卫生系统--塔林宪章"的卫生改革框架,卫生服务的筹资模式已经成为欧洲卫生改革的重点.本文从卫生筹资的角度系统地介绍了欧洲国家近年来所实施的改革政策与措施.通过增加公共财政投入、建立多元化的筹资模式、维护医疗保险制度的稳定性、提高统筹基金的抗风险能力以及改变支付方式来加强政府卫生...     

新医改与我国医疗卫生体制的公平性

医疗体制的公平是每个人基本权利的保证条件之一,我国经济快速平稳增长,医疗体制的公平性却不断受到质疑。在宏观形势与医疗体制自身需要的契机下,2009年中国开始了被称为"新医改"的医疗卫生体制改革。从医疗体制公平性角度,分析了改革方案中对医疗筹资、医疗支付和医疗服务机构3个方面的公平性考虑,提出加强累进性最强的税收筹资的力度,以及将财政资金更多地用于医疗需求方,即社会医疗保险的支持,以提高医疗筹资和支付的公平程度。坚持公立医院为主导,充分体现医院服务机构的公益性,也是改革方案中对公平性地体现,反映了新医改对公平性问题的高度关注。最后提出有待进一步明确的关于政府主导与市场调节的兼顾问题,农村医疗保障的完善、医疗筹资中公共资金的适度比例以及中医药的重新定位和重点发展。     

Health USA. A national health program for the United States.

The Health USA Act of 1991 addresses two fundamental health services financing problems: the more than 30 million uninsured persons and the rising costs for health care and for health insurance. Health USA would provide coverage of the entire resident population for comprehensive medical and preventive health and long-term care services through a universal tax-funded financing system. The federal government would contribute an average of 87% of program costs to each state, which would establish, under federal guidelines, a state health program. Each individual or family may enroll in any health plan approved by the state program, including many private plans, or a plan run by the state program. Through the approved plan of their choice, enrollees would receive covered services and obtain their care from participating physicians and other professional practitioners, hospitals, and other facilities. The state program would pay approved plans a capitation payment for every person enrolled. The plans would pay professional providers fees, as part of an all-payer system of fee schedules and expenditure targets, or capitation payments or salary. Hospitals would be financed through global budgets negotiated by the state program with each hospital. The plan run by the state program would pay the health care costs of any person who does not enroll in an approved plan, making the state plan the payer of last resort and eliminating uncompensated care and cost shifting by providers. Health USA would separate health care coverage from employment, ensuring uninterrupted coverage and eliminating employers' administrative role in providing coverage. Federal and state taxes would replace present methods of financing by private insurance premiums and large out-of-pocket expenditures. Building on the present system of health plans, Health USA would offer all persons a wide choice of competing plans in which to enroll and offer professional providers a wide choice of plans in which to practice. It would control costs by increasing financial accountability of providers and health plans, reducing present reliance on intrusive utilization review and on patient cost sharing. By controlling health care and administrative costs, Health USA would cover the entire population and, according to independent cost estimates, reduce national health expenditures by $11.5 billion in 1991.     

Medical students' opinions on economic aspects of the health care system

Responses of 423 freshmen and 410 seniors at Jefferson Medical College in 1980-81 and 1982-83 to 15 questions on economic aspects of the health care system were compared. A majority of the students considered the cost of medical care, the cost of medical education, malpractice claims, and the failure of individuals to assume responsibility for their health to be major problems. A majority of the seniors also considered excessive government influence on the financing of medical care a major problem. More freshmen than seniors favored national health insurance and health maintenance organizations. More seniors than freshmen supported the professional standards review organization concept and action to discourage increases in the supply of physicians. Concern about the number of physicians entering the profession increased among seniors between 1981 and 1983. The data suggest that at graduation the students were more concerned about the position of physicians but might not be more informed about important aspects of the functioning of the health care system than they were at entry.     

Social health insurance: A knowledge-do gap in eastern Nepal

Health care costs, and those for inpatient care in particular, pose a barrier to seeking health care, and cost be a major cause of indebtedness and impoverishment, particularly among the poor. The Ministry of Health in Nepal intends to initiate alternative financing schemes such as community and social health insurance schemes as a means to supplement the government health sector financing source. Social Health Insurance (SHI) is a mechanism for financing and purchasing / delivering health care to workers in the formal sector regulated by the government. Considering all these facts BP Koirala Institute of Health Sciences (BPKIHS) has introduced SHI scheme in 2000 as an alternative health care financing mechanism to the community people of Sunsari and Morang districts. In the beginning small area was elected as a pilot project to launch the scheme. A major objective of SHI is to reduce poverty caused by paying for health care and to prevent already vulnerable families from falling into deeper poverty when facing health problems. A total of 26 organizations with 19799 populations are at present in SHI scheme. Sixteen rural based organizations with 14,047 populations and 10 urban based organizations with 5752 people are the beneficiaries in this scheme. BPKIHS SHI Scheme is the outcome of the visionary thinking on social solidarity and as an alternative health care financing mechanism to the community. BPKIHS is mobilizing people's organizations and is offering health services through its health insurance scheme at subsidized expenses. This has helped people to avail with health facilities who otherwise would have been left vulnerable because of their penetrating health needs. There is huge gap between premium collection and expenditures. The expenditures are more and this may be due to knowledge - do gap in the program. If conditions are unsuitable, SHI can lead to higher costs of care, inefficient allocation of health care resources, inequitable provision and dissatisfied patients. It can also be more difficult to realize the potential advantages of SHI in future. The future challenges confronting the scheme are to give the continuity and sustainability of the program to its catchments areas. This might entail a shift in its program operation mechanism. People's active involvement is required, which will further provide a sense of ownership in the scheme amongst the people.     

中国农村卫生人力资源现状分析与思考

我国农村卫生人力资源存在的主要问题是数量不足、素质低下、分布不均和结构不合理等,其成因主要是流通渠道不畅、培训机制和筹资机制不健全、城乡地域不均衡。建议加大政府投入,改革人事制度和分配机制,实行有效的激励机制。     

Facing the challenges: general practice in 2020

A strong primary medical care system is essential to the equity, efficiency and effectiveness of the health system as a whole. General practice in Australia faces significant challenges to its capacity to fulfil its role and function: in its financing, recognition, capacity to provide comprehensive care, and integration with the rest of the health system. Addressing these challenges requires a better system of remuneration for quality in general practice care, strengthening of the role of the generalist within the health system, involvement of Divisions of General Practice in service development, and establishment of collaborative networks and integrated primary health care services.