整合服务改革中基于绩效的集团总额预付模式探索及效果

目的:探索适宜我国区域医疗服务体系改革的混合预付支付模式,并论证其效果。方法:借鉴国内外医疗集团支付模式,设计以"按疾病测算+集团打包预付+单病种付费+绩效管理"为核心的集团总额预付制,并通过准实验的政策干预对照试验,利用差分模型,论证该支付方式在控费和改善服务协作方面的效果。结果:从4个乡镇中筛选符合病种纳入标准的住院报销样本共38 980条,以及两级住院病历共194份,发现相对对照组,实验组每人每5个月平均住院率下降0.08%,三级医院住院服务风险比下降0.16%,服务连续性上升了33.80%。集团总额预付制有助于降低住院结构、促进医疗协作,但实际效果因基层首诊和双向转诊制度未能很好执行受到一定影响。结论:建议未来医联体改革应以激励医疗协作、改善服务质量为目标,以分级诊疗和信息共享为基础,在循证基础上配合实施适宜的混合预付模式。

Design and Effect of Performance-based Prospective Global Budget Payment Mechanism in Integrated Medical Delivery System

Objective: To explore and test a new blending prospective payment that works for integrated care delivery system. Methods: Referring to Accountable Care Organization and domestic reforms, we designed a performance-based and prospective global budget payment mechanism which mainly contained strategies as medical alliance contract, prepay by DRGs and performance-based management. Through a quasi-experiment (2 towns in control and treated group respectively, and lasted from 2012-2014), we tested its effects on controlling the inpatient spending and continuity of care. Results: There were 38,980 cases included from inpatient claims data and 194 medical records that from township- and county hospitals. Compared to control group, the average hospitalization rate in treated group significantly declined by 0.08%, the likelihood of using upper level hospitalization significantly declined by 0.2%, and the continuity of care significantly increased by 33.8%. However, the effects of new model might be underestimated by the imperfect implementation of compulsory referral system. Conclusion: The medical alliances should center on combined objectives as stimulate medical cooperation and improve on quality of care. They also should make the blending prospective payment decisions on basis of information-shared grading and referral medical system and empirical evidence