上海市医疗保险总额预算管理的主要成效与问题

2002年以来,上海市医疗保险总额预算管理经历了探索期、发展期和成熟期三个阶段,主要做法包括总额预算、按月预付、分类缓付、按季结算,按季通报、半年考评,年终清算、考核和超支分担,推行“四项公开”和“三轮协商”办法等。经过改革,医疗费用增速得到有效控制,医院自我管理的积极性得到提高,进一步强化监管机制,从而为医院改革营造了良好环境,但目前的改革也面临一些问题：医疗机构内部管理不够规范,费用控制与参保人医疗需求之间矛盾突出;并且缺乏一系列有效的措施。建议从优化预算指标、强化监管、开展支付方式改革等方面进一步完善医疗保险总额预算管理。

Effects and problems in the global budget management of health insurance in Shanghai

Since 2002, the global budget management of health insurance in Shanghai has gone through three stages: exploration, development, and maturity. The main practices include global budget, prepaid by month, postponement of payment by categories, settling accounts by season, circulating information by season, half-yearly evaluation, year-end liquidation, assessment and cost overruns sharing, and the implementation of "giving four items publicity" and "three rounds of negotiation." The reforms have controlled medical expenses, encouraged hospital self-management, created a good environment for hospital reform, and strengthened the monitoring mechanism. However, there are still some problems with reform, including lack of standardization in the internal management of medical institutions, contradictions between cost control and health service, and lack of effective supporting measures. We recommend a three-pronged approach to perfecting global budget management: optimizing indicators, strengthening supervision, and developing payment reform.