社区卫生服务综合改革中医疗保险的现状与分析

Status and Analysis of Health Care Insurance in Comprehensive Reform in Community Health Services

社区卫生改革中"医保预付制和收支两条线"政策的应用和推广,有助于从成本上约束和规范社区卫生服务机构的医疗服务提供行为,使其趋利倾向得以降低;但各国改革的实际经验显示,部分社区卫生服务提供方存在不合理检查、不合理治疗、不合理用药、不合理住院和不合理收费等行为,造成医疗资源的浪费和医疗保险费用的不合理使用,有悖于"医保预付制和收支两条线"政策的设计理念。本研究对国外及国内各地区社区卫生改革的做法进行了现状分析,并提出了相应的对策。

The implementation and popularization of the policy of ＂ pre - paid medical insurance system and separating revenue from expenditures＂ is helpful to restrain the cost and normalize the medical practice in community health services institutions, consequently reducing the profit - seeking tendency. However the experience with medical reform in many countries has shown that part of the community health service providers have some problems, such as unreasonable examination, unreasonable treatment, unreasonable medication, unreasonable hospitalization, and unreasonable charge, resulting in waste of medical resources and unreasonable use of health insurance expenses, which is contrary to the design of the policy of ＂ pre -paid medical insurance system and separating revenue from expenditures＂. Here we have studied and analyzed the situations of both abroad and at home in reform of community health care. And we also put forth the corresponding countermeasures.