医保包干、按服务量付费与医疗费用控制

医院问题日趋严重，关键点在于补偿机制。鉴于原有补偿机制带来的痼疾已经根深蒂固，小修小补式的政策调整实难奏效，需要进行根本性变革。一个可行的策略是改革医保偿付方向，从直接对医院偿付走向对医院集团偿付；改革医院补偿方式，从按项目走向按服务量、按服务人口数量或按疾病数量。如此，将有助于保持医保资金平衡、加强医院监管、控制医疗费用过快增长。     

多元化医保支付方式对医院管理能力的影响

随着国家医疗卫生的改革的不断深入,社会医疗保障体系逐步完善,全民医保网络初步形成,也实现了医保支付方式多元化发展。医保制度改革的目的就是促进社会保障体系正常运行,以进一步控制医疗费用的增长幅度,解决人们"看病难""看病贵"的问题。医保支付制度的改革使按服务项目收费、按服务单元收费、按病种付费、按人头付费以及按预算总额付费等多元化医保支付方式与现行医保制度相适应,逐步增强医务人员的管理责任意识,合理调整医院各科室组成部分,进而有效提升公立医院的服务质量及整体管理水平,促使医院发展更规范、更理性。     

我国医保支付方式改革的有效性边界研究

从理论角度阐述我国医保支付方式改革对医疗服务结果影响的作用机制,并分析医保支付方式在医改中的功能定位及该项改革工作在实现预期效果方面的有效前提。结果表明,支付方式改革可视作公立医院改革的重要抓手,但不是改革的核心。我国医保支付方式改革要实现预期目标,需要同时满足内外部多个传导前提:(1)区域内公共医疗保障程度需达到一定水平;(2)医疗服务供方的筹资体系相对处于封闭状态;(3)需要辅以取消药品加成政策;(4)需要与医院分配制度改革相衔接。按病种支付可以缓解当前医疗费用过快增长的压力,但无法从根本上避免公立医院的逐利倾向。同时改革过程中警惕异地就医可能带来的跨域性医保财政逆向转移的陷阱。     

我国收付费协同的医保支付方式改革现状及发展趋势*

医保支付方式改革是医药卫生体制改革的重要抓手，也是形成“运行新机制”的必要措施，而实现收付费一体化与协同则是深化医保支付方式改革的必然要求。这不仅有利于提高医保基金的使用效率，也有利于从制度上减轻患者的经济负担。文章主要以DRG收付费为例，分析我国收付费协同的医保支付方式改革现状。研究发现：我国在开展的医保支付方式改革中，大多数地区只做到医保付费端，而医院收费端仍是按项目收费，即采用的是“收费”与“付费”并行的双轨制管理办法。尽管我国有福建省三明市等少部分地区逐步开展了收付费协同的医保支付方式改革探索，但“收—付”两端的协同改革仍须强化，同时“政策组合拳”的跟进也至关重要。     

医院也要有作为

正与医保管理部门的"开源"相比,医院的"节流"更为重要。当前,医院管理体制和药品市场改革尚未完善,以药补医、过度检查、药品价格虚高等问题仍然存在,加重了公众就医负担,造成医保基金过度消费。因此,必须从根本上抑制医疗费用不合理增长,挤掉医疗消费中的水分,这样"开源"才有效。医院必须强化医疗行为规范及控费观念,落实服务协议和支付方式改革要求。调动行政、后勤部门和临床医技     

化繁为简，医保支付价可“落地”

从2013年年初起，医药卫生行业就一直在传言国家价格主管部门将改变药品定价方式，正在研究探索制定类似德国等国家医保支付指导价格。在国家很多政策文件中也曾提到改革医保支付方式。但时至今日，依旧不见相关政策落地，医保支付价的改革可谓“只见楼梯响，不见人下来”。     

浅析医保支付方式改革对公立医院运营管理影响及应对策略△

近年来,我国大力推进以DRG和DIP为代表的医保支付方式改革,以此引导医院高质量发展方向,提升医保基金运行效能。作者首先分析了DRG和DIP支付方式改革进展,基于国家政策要求汇总了下一阶段改革方向与时间进度要求。文章提炼了医保支付方式改革对医院运营管理带来的深远影响,包括控制医疗费用不合理增长、医院病种结构调整滞后等。在此基础上,从进一步提高医院运营管理认识、优化调整病种收治结构、加强药品耗材管理等方面提出了推进医院运营管理、积极应对医保支付方式改革的策略。     

美国按价值支付实践及对我国的启示

医保支付方式的改革是深化医改的重要组成部分,其对医疗服务提供者的行为具有重要的导向作用。美国医保支付改革的最新进展为推行“按价值付费”。文章采用文献研究法,对美国实施按价值付费的发展历程进行梳理,发现美国的支付方式改革主要针对医院和医师这两类对象展开,具有奖惩结合、横向和纵向评价相结合、持续改进评价体系、充分发挥信息化手段等特点。结合我国国情,提出今后医保支付方式改革应建立有效的激励机制、制定科学的评价体系、坚持持续优化的机制和加强医疗数字化建设等建议。     

基于选择行为激励的医疗服务价格改革初探

医疗服务价格形成机制是卫生经济学的底层制度, 深刻影响医生的诊疗行为和医院的运行模式。浙江省温州市瑞安市基于医院采购环节的药品耗材品规选择和使用环节的医生合理诊疗行为腾出药品耗材费用空间, 将腾出空间的68%用于提高医疗服务价格, 选择护理、中医、诊察类等248个成本倒挂明显的医疗服务项目, 按照约定的腾空间额度来确定调价幅度;并应用支付宝信用机制同步实施"腾空间调结构", 以解决医疗、医保博弈问题, 拓宽医疗服务价格改革"平移补偿法"的路径, 并与医保支付方式改革产生政策叠加联动效应, 取得较好成效。     

对深化上海医改的几点思考

国家医改方案已经公布,上海医改设计时必须注意处理好组建医疗联合体、管办分离、医保改革、医院补偿机制、全科医师培养、发展高端医疗服务业这六方面的问题。分析了组建医疗联合体必须克服的四个障碍;管办分离的精髓是政府卫生行政部门与医院院长间真正意义上的职责边界合理与清晰;医保改革应由医疗保险向健康保障模式转变,处理好“一卡通”与“个人帐户”问题;医院补偿机制应着重处理好政府财政、医疗服务收费与药品收入三者的关系,在核定支出前提下,医院收支结余部分上交是实现公益性回归的途径之一;社区卫生服务中心医师不必全部是全科医师;关闭公立医院开展的特需医疗服务是吸引社会资金举办高端医疗服务业的最佳途径。最后提出“三包一线”,即建立上海市公共卫生服务包、基本医疗服务包、基本药品包及个人自负封顶线的上海市医改基本思路。     

研究开发与医院医工部门发展探析

技术进步引起产业更替加速、产品生命周期缩短，专业技术优势垄断等特征。医院医工部门面临机遇和挑战，技术创新是一个从构想到商业化的系统过程，本文结合医院工部门的实际情况和内外部环境，选择创新链上的开发研究环节来作为医院医工部门适应变化的发展战略，尝试分析其可行性，提出必要性和实施过程与方式。     

Medical education and the corresponding professional needs of young doctors: the Finnish Junior Physician 88 Study

Summary. The Universities of Kuopio and Tampere in collaboration with the Ministry of Social Affairs and Health and Finnish Medical Association carried out the 'Junior Physician 88' study in 1988, the purpose of which was to shed further light on the life situation and future plans of young doctors and their views concerning undergraduate and postgraduate medical education. The study concerned all the doctors registered during the years 1977–1986 in Finland (   n = 5208  ). After randomization, a postal questionnaire was sent to one half (   n = 2631  ) of these doctors. After the first reminder letter, 1745 questionnaires (66.3%) were returned. According to the views of the respondents undergraduate hospital teaching was adequate but the teaching of practice in health centres, school health care, team-work, health care of the elderly, home health care, rehabilitation, environmental health care and administration did not meet the professional needs of doctors. All doctors were satisfied with the hospital teaching in their undergraduate curriculum. However, only the doctors who graduated from the two modern universities in Kuopio and Tampere were satisfied with their undergraduate health centre teaching.     

The development of a scale to measure medical students' attitudes towards communication skills learning: the Communication Skills Attitude Scale (CSAS)

INTRODUCTION: There is little research identifying medical students' attitudes towards communication skills learning. This pilot study outlines the development of a new scale to measure attitudes towards communication skills learning. METHODS: First- and second-year medical students (n = 490) completed the 26-item Communication Skills Attitude Scale (CSAS) and 39 students completed the CSAS on a second occasion. Factor analysis was conducted to determine the factors underpinning the scale. The internal consistency of the subscales was determined using alpha coefficients. The test-retest reliability of the individual scale items were determined using weighted kappa coefficients and the test-retest reliability of the subscales were established using intraclass correlation coefficients. RESULTS: Maximum likelihood extraction with direct oblimin rotation resulted in a 2-factor scale with 13 items on each subscale. Factor I represented positive attitudes towards communication skills learning and factor II represented negative attitudes. Subscale I had an internal consistency of alpha=0.873 and an intraclass correlation of 0.646 (P < 0.001). Subscale II had an internal consistency of alpha=0.805 and an intraclass correlation of 0.771 (P < 0.001). The majority of items on the positive (n=9, 69.2%) and the negative attitude subscales (n=8, 61.5%) possessed moderate test-retest reliability. DISCUSSION: The development of a new and reliable scale to identify medical students' attitudes towards communication skills learning will enable researchers to explore the relationships between medical students' attitudes and their demographic and education-related characteristics. Further work is needed to validate this scale among a broader population of medical students.     

Medical specialization in Europe: the way forward Promotion of educational quality

Summary. The medical specialties are being intensively reconsidered in the countries of Europe. The important need is for promoting improvement of educational training programmes. Evaluation and improvement of specialist training programmes is the priority and not the setting up of qualifying examinations. The first necessity is to safeguard 20 years of evolution in postgraduate training. Support for the educational process is essential, to a much greater extent than occurs at present, if standards are to be improved and the confidence of the public is to be retained. The EC medical education system is the only existing international structure in medical education which is controlled by law, and is on that basis alone of the greatest interest.     

Development and validation of the Attitudes Towards the Homeless Questionnaire

CONTEXT: The homeless are a significant group within society, which is increasing in size. They have demonstrably greater physical and mental health needs than the housed, and yet often have difficulty accessing primary health care. Medical 'reluctance' to look after homeless people is increasingly suggested as part of the problem. Medical education may have a role in ameliorating this. OBJECTIVES: This paper reports on the development and validation of a questionnaire specifically developed to measure medical students' attitudes towards the homeless. METHOD AND RESULTS: The Attitudes Towards the Homeless Questionnaire, developed using the views of over 370 medical students, was shown to have a Pearson test-retest reliability correlation coefficient of 0.8 and a Cronbach's alpha coefficient of 0.74. CONCLUSIONS: The Attitudes Towards the Homeless Questionnaire appears to be a valid and reliable instrument, which can measure students' attitudes towards the homeless. It could be a useful tool in assessing the effectiveness of educational interventions.     

Barriers to acceptance of medical error: the case for a teaching programme

There is need for a teaching programme aiming to impart a tolerance of error to undergraduate medical students. The implementation of such a programme may have to challenge the institutional norms that encourage authoritarianism, intolerance of uncertainty and denial of error. Acceptance of error is a prerequisite for its candid reporting, and reporting of errors is a prerequisite for their analysis with a view to their prevention. A curriculum on medical error may, therefore, not only help medical students cope with their future mistakes, but also reduce their frequency. Teaching intervention aiming to promote an acceptance of medical error as both inevitable and reducible may also encourage students' epistemological development by making them realize that their doubts and uncertainties are shared by their peers and instructors.     

Student perceptions of the learning environment in a new medical school

Students' perceptions of their learning environment in the Faculty of Medicine of the University of Newcastle were tested in 1979, in the second year of the school's existence, when the first two cohorts of students were surveyed. It was thought important to re-test those same cohorts in 1982, when they were in the later years of the curriculum, to see whether their perceptions had changed, and also to test the perceptions of subsequent cohorts of students (still in the earlier years of the course) to examine whether the favourable perceptions of the earlier cohorts were being maintained. Accordingly, this paper reports the results of a cross-sectional study undertaken on all five years of Newcastle medical students in 1982, and it compares their perceptions with those obtained 3 years earlier.     

Composite undergraduate clinical examinations: how should the components be combined to maximize reliability?

BACKGROUND: Clinical examinations increasingly consist of composite tests to assess all aspects of the curriculum recommended by the General Medical Council. SETTING: A final undergraduate medical school examination for 214 students. AIM: To estimate the overall reliability of a composite examination, the correlations between the tests, and the effect of differences in test length, number of items and weighting of the results on the reliability. METHOD: The examination consisted of four written and two clinical tests: multiple-choice questions (MCQ) test, extended matching questions (EMQ), short-answer questions (SAQ), essays, an objective structured clinical examination (OSCE) and history-taking long cases. Multivariate generalizability theory was used to estimate the composite reliability of the examination and the effects of item weighting and test length. RESULTS: The composite reliability of the examination was 0.77, if all tests contributed equally. Correlations between examination components varied, suggesting that different theoretically interpretable parameters of competence were being tested. Weighting tests according to items per test or total test time gave improved reliabilities of 0.93 and 0.81, respectively. Double weighting of the clinical component marginally affected the reliability (0.76). CONCLUSION: This composite final examination achieved an overall reliability sufficient for high-stakes decisions on student clinical competence. However, examination structure must be carefully planned and results combined with caution. Weighting according to number of items or test length significantly affected reliability. The components testing different aspects of knowledge and clinical skills must be carefully balanced to ensure both content validity and parity between items and test length.     

Towards the identification of student learning problems: the development of a diagnostic inventory

An understanding of how students approach their learning has important implications for medical education. Of particular interest is the fact that the approach students use in their study has a significant impact on both the quality of the learning and their academic success. It would clearly be of value to identify students whose approach to learning was predictive of unsatisfactory performance. This paper describes the initial development of two versions of an inventory (questionnaire) which was designed to aid in the diagnosis of student learning problems. Preliminary information is given on the reliability and validity of these instruments. Factor analyses support the underlying design. Correlation of subscales with academic performance has provided encouraging evidence of the potential of these inventories in identifying students with specific learning or study problems.