英国“购买与提供分开”下的健康服务整合改革及启示

以人为本的整合型卫生服务体系是当前国际卫生体系发展的重要方向。鉴于英国卫生体系综合绩效在发达国家中的领先地位，在"购买与提供分开"的框架下政府同时负责筹资和服务组织的结构，这与我国卫生体系具有相似性，本文根据文献研究和现场调查，分析英国近年建设以人为本整合型卫生服务体系的内在逻辑和实践进展，并探讨其对我国的启示。研究发现，改革主要体现在三个层面：区域层面推动卫生部门内部各机构与跨部门服务的统一规划，并辅以转型基金、绩效考核和整合式的预算分配与决策机制；地方层面以公共卫生和医疗服务的筹资整合推动服务围绕人群健康进行协调，应对人群层面的健康问题；社区层面通过对全科医生执业模式进行再组织，在基层卫生网络基础上结合社区服务，综合应对个体和社区层面的健康决定因素。根据英国经验，本文提出：整合改革涉及多个层面，应当明确各自权责；统一的决策问责、协调的资源分配是推动整合的关键抓手；基层卫生发展需要在专业化基础上进行组织化。     

经济发展与卫生政策思考

笔者随中国卫生经济网络组织的广东省卫生改革考察组行程１４００公里，考察了１４个卫生行政机构和近４０个卫生服务组织，感触颇深，主要有以下几点；其一，政府在公共货物和外延效益好的卫生服务方面的职能与作用不同经济发展水平的不同而不同；政府对卫生机械的宏观调控能力来自于财政状况及自身的职能转变；政府对贫困地区的卫生投资是减少贫困的有效途径之一。其二，随着经济的发展需求的变化，卫生服务机构应及是提供与之相应     

发挥政府、市场积极作用 合理配置卫生资源

一、卫生改革时期卫生工作的成绩与问题随着社会主义市场经济体制的建立，卫生改革伊始，我国便借鉴了美国的自由开放式卫生服务模式，按照市场经济思想指导卫生改革。这个时期卫生事业由过去中央统一领导的管理体制改变为在中央宏观指导下分级管理，以地方为主的条块结合的管理体制；筹资方式也由单一的政府投入转变为由各级政府、部门、行业、社会团体以及个人多方筹资；卫生事业活动中存在的经济规律开始被认识，并逐渐被应用于实际工作；有关卫生服务收费政策得到逐步调整和完善。通过改革，转变了传统计划经济体制下单纯依靠和等待指令…     

关于中国西部农村卫生发展的思考

西部大开发带来了西部农村卫生改革与发展的契机。处理好公平和效率的关系；协调好政府职能与社会作用、中央政府作用与地方政府作用、卫生发展与经济发展的关系，西部农村卫生事业才能得以健康发展，中国卫生事业才能持续发展。     

胡鞍钢：中国需要高瞻远瞩的卫生产业发展战略

目前，医改的基本思路和框架已经确定，最鲜明的一点就是要加大政府投入。坚持为人民健康服务的宗旨，投资于人民健康应该是中国卫生改革和发展的战略核心。我在《卫生与发展：建设全民健康社会》里就写过，政府要转换和丰富职能，要投资于人民：投资于人民卫生、投资于人民健康、投资于人民健身，建设国家卫生保障系统。中国将成为最大的健康社会，创造最大的卫生服务产业和卫生消费市场，真正意义上成为具有丰富内涵的“全民健康社会”。     

关于构建与和谐社会相适应的卫生服务制度的思考

为构建与和谐社会相适应的卫生服务制度，针对我国卫生服务制度中存在的与构建和谐社会不相适应的问题和矛盾，本文从现实和理论的角度，采用综合与分析的方法，探讨卫生服务制度设计的指导思想、基本原则、方法内容和保障措施。构建与和谐社会相适应的卫生服务制度，必须统筹城乡之间、区域之间、预防与医疗之间、中医与西医之间、医疗服务与医疗保障之间、不同层次卫生服务之间、公立医疗机构和民营医疗机构之间的均衡发展，改善医患关系．加强卫生监督执法，规范医疗卫生服务市场秩序。在保障措施上，必须强化政府责任，加强部门协调，注重配套改革。要实现卫生事业和谐、健康、快速发展，卫生改革与发展成果惠及广大人民群众，必须构建和谐社会相适应的卫生服务制度。     

借鉴国际卫生改革经验完善我国卫生改革政策

在计划经济时期，我国的卫生工作借鉴的是英国卫生服务模式，实行的是以国家为主导的福利型卫生事业。随着社会主义市场经济体制的建立，卫生改革起始，便借鉴了美国的卫生服务模式，按照市场经济思想指导卫生改革。在经过若干年的实践之后，卫生工作出现如下一些问题：①医疗费用急剧上涨；②医疗秩序陷于混乱；③城乡之间、上层与基层之间、医疗与预防之间差距扩大；④健康保障制度薄弱。痛定思痛，我们不得不去思考，国际卫生改革与发展的趋势是什么？我国的卫生改革要从国际卫生发展中汲取哪些经验教训？制订具有中国特色的卫生改革政策…     

新世纪卫生产业发展面临的挑战与对策

文章首先分析了卫生产业的特征，其次阐明了新世纪卫生产业发展面临的挑战：一是卫生产业是目前我国既有公共投资和私人投资，又有公共消费和私人消费最大的服务产业一；二是健康消费，医疗卫生服务需求是最重要的国内居民消费热点之一，也是今后扩大国内投资需求的新增长点；三是稀缺的卫生资源与医疗需求之间的矛盾始终是我国卫生事业发展的“瓶颈”；四是现行的卫生服务体系或办医模式客观上抑制和阻碍着社会对医疗需求的增长，加快变革体制势在必行；五是医疗费用增长过快，服务满意度有所下降；六是认识上存在误区；七是卫生政策改革滞后于卫生事业的发展；八是宏观调控失灵。最后提出了新世纪卫生产业的发展策略：一是大力推动健康消费；二是彻底转变观念；三是重新定位政府卫生资源配置职能，调整公共卫生政策取向；四是引入竞争机制，打破垄断，分类重组国有医疗卫生机构；五是允许和鼓励非公有制经济参与医疗卫生产业；六是扩大公立医疗卫生机构经营自主权，加强内部经营机制的改造；七是拓宽卫生筹资的手段和途径，形成多元化卫生筹资新格局。     

经济发展与卫生政策思考──广东考察的启示

笔者随中国卫生经济网络组织的广东省卫生改革考察组行程１４００公里，考察了１４个卫生行政机构和近４０个卫生服务组织，感触颇深，主要有以下几点：其一，政府在公共货物和外延效益好的卫生服务方面的职能与作用不因经济发展水平的不同而不同，政府对卫生机构的宏观调控能力来自于财政状况及自身的职能转变；政府对贫困地区的卫生投资是减少贫困的有效途径之一。其二，随着经济的发展需求的变化，卫生服务机构应及时提供与之相应的卫生服务，并为因需求变化可能出现的新需求作好提供服务的准备；政府（卫生行政）则应从供方控制的角度抑制因过多供给而牵拉出的需求和诱导需求。其三，对于富裕起来的农村，政府仅提供基本医疗保证，其他服务的提供则由市场决定；在保障制度方面，政府则应着力于建立大病风险共担的机制而不是停留在基本医疗服务的提供上。其四，对慢性非传染性疾病多发的城市，政府在卫生政策和计划上可着力于扶持推广社区卫生服务。     

论社区卫生服务

一、发展社区卫生服务是我国政府的既定方针改革城市卫生服务体系，发展社区卫生服务，是我国城市卫生改革的方针，是21世纪我国城市卫生服务的发展方向。中共中央、国务院（关于卫生改革与发展的决定）第八条，明确规定要“改革城市卫生服务体系，积极发展社区卫生服务，逐步形成功能合理，方便群众的卫生服务网络”。中共上海市委、上海市人民政府（关于加快卫生改革与发展的若干意见）第八条，也明确规定了“要优先保证和发展社区卫生服务，把加强社区卫生设施建设，实施城乡初级卫生保健和社区卫生服务，作为改革和完善卫生服务体系的重…     

Accounting for future costs in Medicare

The relationship between the health of an insured population and the costs of insuring them is a lot more complicated than might first appear. The excellent paper by Geoffrey Joyce and colleagues helps explain why. The obvious interaction between health status and longevity, interacting with the issue of how long the insurer remains responsible for care of a particular person, is central. So is the cost of improving health status. And perhaps most importantly, the relationship between health care use and costs in the United States is not as straightforward as is generally assumed.     

美国医改实施的进展、前景与启示

美国医改实施三年来,在扩大医保可及性、改革医疗服务市场、降低医疗费用和改进服务质量方面取得较大进展,但许多触及既得利益集团的核心改革政策如建立保险交易所、改革支付方式、削减部分福利项目、提高富人税率等开源节流措施尚未正式启动,这将成为奥巴马连任后面临的主要挑战。美国医改鼓励服务的整合、改革支付制度、重视预防保健服务等做法值得中国医改借鉴,同时以商业医疗保险为主导的保险体系暴露出的弊端也启示中国政府以更加审慎的态度发展商业医疗保险。     

Why reduce health inequalities?

It is well known that social, cultural and economic factors cause substantial inequalities in health. Should we strive to achieve a more even share of good health, beyond improving the average health status of the population? We examine four arguments for the reduction of health inequalities.1 Inequalities are unfair.Inequalities in health are undesirable to the extent that they are unfair, or unjust. Distinguishing between health inequalities and health inequities can be contentious. Our view is that inequalities become "unfair" when poor health is itself the consequence of an unjust distribution of the underlying social determinants of health (for example, unequal opportunities in education or employment).2 Inequalities affect everyone.Conditions that lead to marked health disparities are detrimental to all members of society. Some types of health inequalities have obvious spillover effects on the rest of society, for example, the spread of infectious diseases, the consequences of alcohol and drug misuse, or the occurrence of violence and crime.3 Inequalities are avoidable.Disparities in health are avoidable to the extent that they stem from identifiable policy options exercised by governments, such as tax policy, regulation of business and labour, welfare benefits and health care funding. It follows that health inequalities are, in principle, amenable to policy interventions. A government that cares about improving the health of the population ought therefore to incorporate considerations of the health impact of alternative options in its policy setting process.3 Interventions to reduce health inequalities are cost effective.Public health programmes that reduce health inequalities can also be cost effective. The case can be made to give priority to such programmes (for example, improving access to cervical cancer screening in low income women) on efficiency grounds. On the other hand, few programmes designed to reduce health inequalities have been formally evaluated using cost effectiveness analysis.We conclude that fairness is likely to be the most influential argument in favour of acting to reduce disparities in health, but the concept of equity is contested and susceptible to different interpretations. There is persuasive evidence for some outcomes that reducing inequalities will diminish "spill over" effects on the health of society at large. In principle, you would expect that differences in health status that are not biologically determined are avoidable. However, the mechanisms giving rise to inequalities are still imperfectly understood, and evidence remains to be gathered on the effectiveness of interventions to reduce such inequalities.     

探索首都特色医药卫生体制改革道路

分析了北京医药卫生体制改革的重要策略、实施进展以及主要成效,总结了首都医改的特点:促健康、重管理、保基本、强基层、建机制、提效率,供推进医改工作参考。     

我国医疗服务价格调整与医保支付方式改革的联动机制研究

相较于医药医保、医药医疗间关系的渐趋合理,医保与医疗间协调互动关系仍亟待深入讨论。医疗服务价格动态调整和医保支付方式优化分别是针对供给方和购买方的重要改革思路,两方面改革均有助于提升医疗体系改革成效,本文基于发挥政策合力提升社会福利水平的研究目标分析了如何建立二者的联动机制。主要研究结论是,应遵循激励相容的改革原则,以改善医疗机构行为作为联动机制的关键政策节点,通过构建互动嵌套的优化机制发挥政策合力。此外,联动机制的良好运转也需外部协同治理。建议应推行健康管理促进居民生活方式科学化、推进医联体建设提高优质医疗资源共享水平以及推动互联网与医疗服务的进一步产业融合化。     

Putting people first: health care our families can afford

With U.S. health care costs expected to reach 16.4 percent of the gross national product by the year 2000, the nation can no longer afford not to have a national health care plan. The reciprocal problems of cost control and access to health insurance can be addressed by implementing health expenditures targets and market reform guaranteeing coverage, reforming health care insurance, improving our primary care delivery system, and improving health education. Such a program will enable America to have the confidence and productivity necessary to achieve global economic leadership.     

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。     

社区卫生服务必须建立适应市场经济的运行机制

社区卫生服务是在市场经济的大环境下进行的,因此必须树立卫生服务的产业观念,引入市场供求机制、竞争机制、价格机制,遵循经济规律,适应需求水平,才能充满生机和活力。必须走产业化道路;实行微观合理收费;与医疗保障制度改革相衔接;加快总体推进卫生改革的步伐;确立“以人为本”、“需求为导向”等新的观念,社区卫生服务才能有广阔的市场。     

The National Institute for Clinical Excellence (NICE)

In discussions on the development of the institutional framework for decisions on the benefit package of social health insurance in Germany, the English National Institute for Clinical Excellence (NICE) is considered as either a good or a bad example for reform. According to this study, the procedures and criteria applied by NICE for making health care coverage decisions are legitimate. Procedures are transparent and interest groups are broadly represented. Decision criteria include cost effectiveness of services - albeit only if information on cost effectiveness is available and highly evident. Furthermore, cost effectiveness is not the only criteria for coverage decisions. NICE very rarely induces strong direct rationing, but rather leaves room for discretion. However, the trade-off between maximising allocative efficiency and avoiding distributional consequences becomes apparent.     

Do interventions to increase income improve the health of the poor in developed economies and are such policies cost effective?

Health policy has shifted towards placing a greater emphasis on the role of lifestyle and life circumstances in improving health. The factors that are associated with poor health status are known, but the comparative effectiveness of specific policy interventions in improving health and reducing inequalities in health is unclear. For example, there is little evidence that specific policies aimed at providing income support or poverty eradication have any measurable impact on health. Two previous reviews have addressed the evidence in this area but in a fairly restrictive way. One considered only randomised trials and the other excluded non-cash benefits. This article builds on the previous reviews in three ways: a broader scope of study designs and types of intervention is considered; more recent literature is reviewed; and it considers the extent to which an economic evaluation framework has been applied. A systematic search of electronic databases was carried out for literature published since 1980 and in the English language. Each study was appraised in terms of its relevance to the question of interest, and the quality of the study design was appraised in terms of its capacity to provide robust answers. Few studies were found with health outcomes as their main focus. Most of the studies that used secondary data sources or survey data were of poor quality. Where economic evaluations were reported, these tended to be restricted to financial assessments. Different types of interventions were evaluated. In studies of cash benefits, there was limited evidence that they had a positive effect on some health domains, mainly psychosocial. Studies in welfare-to-work interventions produced mixed results in terms of impact on either income or health; there was no consistent relationship between income gains and health improvements. Five welfare-to-work studies included 'benefit-cost analysis', but these were essentially financial assessments. Studies of benefits in kind did not meet the quality criteria for inclusion in this article. Overall, we found no evidence of the potential cost effectiveness of income support or anti-poverty initiatives in improving health, nor is there a strong effectiveness literature on which to build such analysis. However, the hypothesis that increased income may improve health cannot be said to have been properly tested. Studies generally analyse the incremental effect of changes to the welfare system and do not estimate the health effects of current provisions. The production function for good health is complex. Increasing income may be a necessary, but not a sufficient, condition for the creation of better health in those with low incomes.