医联体医保支付研究

Study on medical insurance payment of medical alliance

目的阐述医联体医保支付内涵、国内外典型地区的医联体医保支付实践现况及优缺点,为推进我国医联体医保支付改革提供对策建议。方法利用知网和PubMed等中英文数据库,以"医联体""医共体"和"医保支付"为关键词,检索建库至2021年1月期刊文献。结果各国开展不同的医联体模式(美国ACOs、英国国家医疗服务、德国公共合同型和新加坡医疗集团模式)并积极探索多样精细化的支付方式适应其医疗模式;我国医联体模式(松散型、半紧密型和紧密型医联体)医保支付实践已初具成效,但存在配套措施不完善、信息化建设支撑作用不足等问题。结论构建紧密型医联体,探索混合支付方式,利用信息化建设和绩效考核体系强化政府监管职能,提高医保基金利用率。

Objective This study was to expound the connotation of medical insurance payment,the current situation and advantages and disadvantages of medical insurance payment within medical alliances in typical areas at home and abroad,to provide countermeasures and suggestions for promoting the payment reform of medical alliances in China.Methods Papers were searched by using CNKI and PubMed,Chinese and English databases,with the keywords of"medical alliance","medical community"and"medical insurance payment".Relevant literature were retrieved from the database establishment to January 2021 was searched.Results Various countries had developed different medical alliance models(ACOs in the United States,National Health Service in the United Kingdom,Public Contract in Germany and Medical Group in Singapore)and actively explored diversified and refined payment modes to adapt to their medical modes.The medical insurance payment practice of China’s medical alliance model(loose,semi-close and close medical alliance)had begun to take effect,but there were some problems such as imperfect supporting measures and insufficient supporting role of information construction.Conclusions Close medical alliance should be constructed,mixed payment methods should be explored,information construction and performance appraisal system should be used to strengthen the regulatory functions of the government and improve the utilization rate of medical insurance funds.