我国港澳地区医疗券制度及其对内地的启示

引入市场竞争机制是医疗体制改革的重点和难点。我国港澳地区的医疗券制度能够为内地推进医改体制创新、倒逼公立医院改革和合理配置医疗卫生资源提供借鉴。本文首先介绍了医疗券制度的起源和发展。然后详细阐述了港澳地区医疗券制度的实施背景、异同与政策效果,发现医疗券制度在引导需方更多使用私立医疗服务、提高居民预防保健意识、推广家庭医生制度等方面起到了积极作用。最后对医疗券制度在内地的适用性进行了分析,指出其与内地医改导向相契合,并可作为内地医保制度的有益补充和推动社会办医的有效措施,在完善内地医疗保险、医疗救助制度和发展私立医疗机构等方面具有一定的可行性。     

Diffusion of new technologies: rational and irrational

The diffusion of medical technology, the process by which new clinical procedures and devices come into use in the health care system, is an historical topic, as old as medicine itself. Hospitals, physicians, manufacturers, third-party payers, and patients all are factors in the demand for, and adoption and diffusion of, new medical technologies. The federal government also plays a role both in furthering technology diffusion through federally financed health programs and in attempting to control diffusion by stimulating state certificate of need and other regulatory programs. The history of the CT scanner's diffusion illustrates the problems that can result from the lack of a coherent strategy to control the diffusion of major medical technologies. Some of these same problems are now appearing in the diffusion of magnetic resonance imaging (MRI) devices. In the current health care environment, prospective payment and the continuing period of remarkable technological innovation are major influences on technology diffusion and on initiatives for technology assessment. The diffusion of technology can be made more rational by instituting a formal process to identify technologies (both old and new) that require assessment, by financial support for assessment efforts, by selective reimbursement for clinical trials, and by regionalization of costly procedures.     

Newly implemented health system reform in Israel: physicians' attitudes

OBJECTIVE: To explore the attitudes of Israeli physicians towards the feasibility and potential consequences of the newly implemented health care reform. DESIGN: Physicians' attitudes were examined soon after the enactment of a National Health Insurance Law, the first element of the reform to be implemented. SETTING: A nationwide mail survey. SUBJECTS: A random sample of 2000 practicing physicians. MAIN OUTCOME MEASURES: Attitudes towards the health care system prior to the reform; predicted effects of the reform on health care and medical practice. RESULTS: Most of the respondents think that the system requires a change. Quality of community-based care is expected to increase, in contrast to hospital care. The reform is believed to exert an adverse effect on medical practice. Attitude is significantly influenced by practice setting and speciality: community setting and general practice correlate with less desire for a major change. Specialists believe that reform elements which will shift the balance towards the hospitals will have the greatest benefit on the health system. GPs, compared to specialists, are more optimistic regarding quality and accessibility of services (P<0.01). CONCLUSIONS: Our survey suggested that Israeli physicians favor a change in the health care system, despite a perceived adverse effect of the reform on medical practice. Since the reform is believed to shift the balance from the hospitals to the community, respondents support changes that will compensate for the imbalance.     

The World Bank and pharmaceuticals

Within less than a decade the World Bank has become the largest single source of finance (loans) for health in low and middle income countries as well as a major player in the field of pharmaceuticals. Often 20-50% of the recurrent government health budget in developing countries is used to procure drugs. Drugs are among the most salient and cost-effective elements of health care and often a key factor for the success of a health sector reform. However, pharmaceuticals are frequently being used irrationally, mainly due to market imperfections in health care, such as information asymmetries, leading to serious health problems and a heavy financial burden on the health system. Lending priorities set by the World Bank could be used to promote public health sector reform, leading to the rational use of affordable and available drugs of good quality in developing countries. This report provides the first analysis of World Bank activity in the pharmaceutical sector worldwide. The analysis of 77 staff appraisal reports, describing the planning phase of World Bank country projects, shows that 16% of the total World Bank health, nutrition and population budget, or approximately US$1.3 billion, has been committed to loans or credits supporting pharmaceutical activities in the programme countries between 1989-95. Roughly US$1.05 billion has been committed to procurement of drugs and medical equipment. Only 5% of the total pharmaceutical sector lending is committed to software components such as drug policy work and rational use of drugs. No more than 45% of the projects were developed in collaboration with pharmaceutical expertise. The World Bank is recommended to improve its pharmaceutical sector involvement by promoting drug policy research and development including national and international dialogue on pharmaceutical issues to ensure rational use of both drugs and loans. In this, the World Bank has an advantage given its experience from working with both the private and the public sector, its in-house expertise in health economics, and lastly its ability to be listened to by governments through its power.     

Monitoring health care system performance in Iowa.

Monitoring the performance of the health care delivery system is a public health function that becomes more important as organized delivery systems begin to take control over larger portions of the medical care market. The study reported here illustrates how standard medical care epidemiology can be applied to analysis of health care system performance to aid governmental efforts to monitor new developments in the medical care market. In order to evaluate the efficiency of hospital care delivered in Iowa, age- and sex-adjusted population admission rates for five common procedures were generated for all 99 counties. The five common procedures were defined as follows: hernia, tonsillectomy, cesarean section, hysterectomy, and cholecystectomy. In addition, variations in 11 ambulatory care-sensitive condition rates were analyzed. Residents of at least 15 counties were at significantly greater than average risk of receiving each of the common procedures (chi 2 test, P < 0.05). Counties that had a high rate for one procedure tended to have a high rate for at least one other procedure. Several counties had more than twice the mean rate. Even a 10% reduction, when added across all five common procedures. amounts to well over 2,000 hospitalizations avoided. It is assumed that reductions would be concentrated in high-rate counties. If a 50% reduction could be achieved in only part of the ambulatory care-sensitive procedures, more than 10,000 hospital admissions could be avoided.     

The development of market approaches in Russia

In the late 1980s, it became clear that poor outcomes of the Russian health system were caused not only by underfunding but also by inadequate management of health care. Some features of the system led to great inefficiency in medical care provision and an irrational structure of medical care. The recognition of this fact has intensified the search for new methods of finance and management. The underlying idea of health care reforms in Russia is to weaken providers' dominance, to make them more responsive to consumer preferences, and to change the structure of medical care. The main developments of the reform parallel the reforms in Western countries. These are primarily the separation of finance and provision of medical care, with the shift from an integrated to a contractual model of relationships between payers and providers. But the specific characteristics of the health care situation, primarily the great underfunding and the absolute dominance of state-owned medical facilities, make the reform in the Russian health sector more radical. This paper highlights the issues of the current and planned developments in the Russian health sector. After presenting the main characteristics of the current health systems, it addresses economic experiments which are underway in several regions of the new Russian Federation. They are designed to introduce elements of market relations into a highly bureaucratic system. The main features and the impact of the experiments are discussed. Then the new model of finance, which is based on a transition from tax-financed to the health insurance system, is presented.     

医疗服务供方分担医疗费用风险的探讨

医疗保险制度有效运作的关键是实施适宜的医疗费用控制策略。本文研究分析管理式医疗的特征及应用效益,探讨将管理式医疗的基本原理引入我国职工医疗保险制度,加强医疗服务供方分担医疗费用增长风险的责任。改革支付方式,强化对供方的制约机制;规范医疗服务提供者的医疗行为;对特定人群疾病的疾病管理(Disease Manage-ment）应用;加强医疗保险立法建设;合理控制医疗费用增长,为人民群众提供优质、收费合理的服务。     

医疗保障制度改革对医院的影响

该文根据云南省曲靖市1997年实施医疗保障制度、改革医疗市场供求关系发生的变化、医院运营情况(包括医疗服务量、医疗效率、业务收入、医疗费用等)、医院经济效益等方面的具体情况,结合翔实的数据,就医改运行对医院的影响进行了比较分析。     

Technological change around the world: evidence from heart attack care

Although technological change is a hallmark of health care worldwide, relatively little evidence exists on whether changes in health care differ across the very different health care systems of developed countries. We present new comparative evidence on heart attack care in seventeen countries showing that technological change--changes in medical treatments that affect the quality and cost of care--is universal but has differed greatly around the world. Differences in treatment rates are greatest for costly medical technologies, where strict financing limits and other policies to restrict adoption of intensive technologies have been associated with divergences in medical practices over time. Countries appear to differ systematically in the time at which intensive cardiac procedures began to be widely used and in the rate of growth of the procedures. The differences appear to be related to economic and regulatory incentives of the health care systems and may have important economic and health consequences.     

Improving the implementation of cost recovery for health: lessons from Zimbabwe

In the current debate over health financing policy in developing countries, governments are increasingly focusing on cost recovery--having patients pay part or all of their health care costs--as a way to mobilize more resources for health, improve equity by selectively charging the wealthy, and increase efficiency by encouraging reinvestment of fee revenues into cost-effective primary care. Zimbabwe offers an important example of a country with a tradition of levying fees in government health facilities, but where enforcement became lax in the 1980s. In 1991, policymakers resolved to resuscitate and strengthen cost recovery, as part of a broader economic reform program. This paper discusses the strengths and weaknesses of Zimbabwe's cost recovery system, its potential for improvement, and the obstacles to change in revising the fee structure and billing and collection procedures. It argues that cost recovery can help to achieve Zimbabwe's health objectives, but only in conjunction with other measures to redirect public spending to essential public health and clinic care and improve the efficiency of government services. The paper finds that during the 1980s, the fee schedule became badly misaligned with actual medical care costs and created distortions in patient referral patterns. Billing and collection were also weak, because of deficiencies in personnel and information systems and lack of incentives for revenue generation. The paper concludes that if key steps were taken to raise the collections-to-billings ratio, recover fees from privately-insured patients, and adjust fees in line with medical cost inflation, recoveries could increase fourfold, from 5% to 20% of government spending for clinical care. At the same time, access to government health services for the poor could be maintained by improving exemption procedures.     

分级诊疗制度下考虑患者偏好的医疗服务资源纵向整合研究

分级诊疗制度是现阶段改善患者无序就医、合理配置医疗资源、促进基本医疗服务均等化的重要举措。本文界定了个人可支配收入、年龄、自感疾病严重程度及医疗机构门诊价格、服务容量等多因素影响的患者理性就医行为的效用函数,构建了基于患者就医偏好的就医选择动态博弈模型,通过将理性就医偏好下虚拟行动仿真的秦皇岛医疗机构患者分布与实际统计数据进行比较,验证了所建模型的合理性。研究结果表明:患者在基层医疗机构与高水平医疗机构间的就医行为较理性,在二三级医院间却较不理性。因而分级诊疗制度下医疗服务资源优化的重点在于建立患者按需就医的整合型医疗服务体系。     

The information imperative of outcomes management

Health care providers are being asked to collect, analyze, and evaluate the results of medical processes or procedures to improve the outcome of health care services. The linkage of process to outcome is not a new science, but it has assumed greater importance in today's health care economic climate. Medical effectiveness and outcomes management studies, once within the purview of health services investigators, are moving to the individual provider setting. This evolution has tremendous impact on health information management professionals. As the guardians of the data that are indispensable for medical effectiveness and outcomes management investigations, health information management professionals play a key role in caregivers' attempts to correlate process and outcome performance measures. The article discusses the historical origins of outcomes management, the prominence of outcomes management in health care reform activities, and the responsibilities of health information management professionals in these strategic initiatives.     

落实“十五”发展纲要 构筑新型卫生体系

该文全面阐述了实施《上海市卫生事业发展第十个五年计划纲要》的重要意义 ,进一步明确了实施《纲要》必须坚持以发展为主线 ,强调了改革是推进卫生事业发展的强大动力 ,法制和规制建设是卫生改革与发展的必要保障 ,并提出要正确处理好几个关系 :( 1 )正确处理好政府与市场的关系 ;( 2 )处理好公共卫生与医疗卫生的关系 ;( 3)处理好城市卫生与郊区卫生的关系 ;( 4 )处理好改革发展和规范合理的关系     

新形势下加强公立医院医疗服务项目成本核算的思考

随着公立医院补偿机制和医保支付制度改革的推进,公立医院的成本管理工作越来越受到重视。科学合理的医疗服务项目成本核算可对医院管理机制的完善、补偿机制的建立、医保支付方式改革的推进以及卫生资源的合理有效配置提供重要参考依据。政府部门和公立医院以及社会各界应加强成本管控意识,推动医院医疗服务项目成本核算工作有效开展。     

基于均等化视角省域范围内乡镇卫生院效率分析：以山东省为例

医改进程中区域内医疗服务流向不合理问题凸显,乡镇卫生院作为区域内基本医疗卫生服务的主要提供者,其功能能否正常发挥是实现区域内合理分流的关键。因此,有必要对区域内乡镇卫生院资源配置的公平性和服务效率等基础信息进行分析。文章通过测算基尼系数和DEA效率分析,发现山东省乡镇卫生院处于整体服务能力水平较低的公平状态,乡镇卫生院在现有资源配置状况下,可以提供更多的服务,但现实情况是没有相应的服务对象。研究结果提示应在体系、制度、功能、资源和需求等层面进行综合设计,促使病人下沉到基层。     

论卫生改革成功的必要条件

当前,不仅要讨论具体卫生政策的正误,更需要讨论卫生政策形成机制中存在的问题.具体的政策像产品,形成机制像机器,产品的质量在一定程度上由机器所决定.卫生改革欲达成功之目的,必先有科学合理之决策;欲得科学合理之决策,必须充分认识改革成功的困难性,抛弃主要依靠经验的决策模式,建立并遵守复杂决策的程序和规则,这是卫生改革成功的必要条件.作者还就卫生改革决策需要遵循哪些程序和规则进行了讨论.     

江西基层医疗机构实施临床路径管理之效果和意义

目的：进一步明确基层医疗机构实施临床路径管理的效果和实际意义。方法：对江西省基层医疗机构实施的24种常见病、多发病的临床路径试点情况进行数据采集,录入Excel（2007）进行逻辑检验,并对符合逻辑的数据进行统计学的频数分析和相关分析。结果：全省226家基层医疗卫生机构累计完成人径病例8428例,完成路径病例7856例,让24个试点病种患者得到了全程精细化管理治疗,住院天数降低显著,治疗费用下降明显,治愈率和满意度提高。实施临床路径后住院病人的住院天数下降均超过10％。下降率〉30％的共有11种病,占此次施行24个病种的45．83％;下降率20％～30％,有9种病,占37．5％;下降率20％～10％的有4个病种。治疗费用下降率大于40％的病种有5个,治疗费用下降了20％～40％的病种有5个,占24种病种的20．83％;治疗费用下降了lO％～20％的病种有12种,占50％。医疗机构问卷调查显示在进行诊疗路径管理的机构,诊疗行为更加规范、合理的机构占95．48％;医疗纠纷减少的医疗机构占77．40％;治愈率上升的医疗机构占79．10％;患者满意度提高的医疗机构占84．75％。结论：基层医疗机构实施临床路径管理,医疗供需双方都得到实惠。对规范医疗行为、科学合理确定看病费用、促进双向转诊机制构建、新农合医疗费用支付方式的改革、医务人员医疗水平提升等提供了丰富的实证参考。建议在全国基层开展临床路径试点工作,不断总结和推广,解决广大群众看病难和看病贵。     

卫生筹资中社会卫生支出的预测与分析

目的:本文利用时间序列数据,在ARIMA-FDLMR两阶段分析框架下研究了社会、政府及个人与卫生筹资格局的关系。方法:首先,基于自回归积分滑动平均模型(ARIMA),借助2017年《中国统计年鉴》的数据,预测分析社会、政府、个人的实际卫生支出及其各自占GDP的比重;其次,通过2005—2015年社会卫生支出相关数据,建立时间序列有限分布滞后多元回归模型(FDLMR),分析了医疗卫生体制改革对社会卫生支出产生的影响。结果:ARIMA模型结果显示,社会卫生支出增长速度最快,所占GDP比重最大;政府持续加大医疗投入,但个人卫生支出在短时间内难以降低。FDLMR模型结果显示,社会保险基金支出、非公立医院数量以及社会捐赠对社会卫生支出具有显著影响。结论:鼓励社会资本参与医疗卫生改革是弥补卫生支出不足的有效途径,社会卫生支出将在卫生筹资发展与改革中起到重要补充作用,并且在未来非公立医疗机构将进一步凸显其价值。     

The search for truth: the case for evidence based chaplaincy

Chaplaincy and medical science are in search of truth. Should chaplaincy become more scientific in response to health care reform? Yes is the answer. Chaplaincy ought to become more based in evidence for the following reasons. First, the health care culture is evidence based and chaplaincy needs to speak that language. Second, chaplaincy and science are not opposed. Third, tradition-driven chaplaincy already utilizes medical evidence. Fourth, spirituality is the domain of chaplaincy and other health care disciplines have provided the research in our domain. However, if chaplaincy becomes more scientific, it does not mean that chaplaincy will maintain or grow in its position in health care reform. Health care reform in relation to chaplaincy is driven more by values than evidence.