从改变支付方式入手,求得医改的突破(1):上海市医疗费用“总量控制、结构调整”政策15年来效果及其启示

To explore a breakthrough of health reform in China through changing payment(Ⅰ):the prominent practice effects and hints of the policy called"Global budget,Structure adjustment"in Shanghai

为验证总额预算下、按项目付费方式且合理化收费标准是实现医改突破的有效途径,研究以上海市上世纪九十年代中期出台的医疗费用"总量控制,结构调整"政策作为案例,引用政策实施前后近30年的全国卫生财务年报资料,通过纵向和同期不同地区横向比较发现,医疗费用从政策实施前的年均32.8%高速增长骤降至实施期间的12.5%,略低于期间GDP增长(14.7%),纳医疗费用在社会可承受范围之内,十年间为社会减少了2161.6亿元医疗费用负担,控费效果远超全国和同类城市平均水平。政策所取得的斐然成绩提示研究者和决策者,欲实现医疗费用的有效控制总额预算必不可少。但按项目付费方式下的高额医疗费用风险、物价部门难以协调又使得医疗机构潜在损失难以弥补等问题,均成为了现今看病贵等问题依然存在的桎梏。启示:合理设计总额预算指标以确保费用稳定增长,并需改现有按项目付费方式为预付制。

To prove that the global budget under the ＂fee for service＂ is the efficient approach to realize the breakthrough of health reform,based on 30 years＇ database,the paper takes the policy of ＂Global budget,Structure adjustment＂ as an example.After analysing the case from portrait to landscape orientation,the paper finds that the achievement of the policy is prominent：the increasing rate of medical expenditure in Shanghai declined from 32.8%to 12.5%during policy implementation period,which was below the rate of GDP.216.2 billion yuan were economized in 10 years,so the medical burden was lighter than the whole nation and other cities such as Beijing.The result clues on：the global budget is crucial,but risk of high medical expenditure caused by fee for service and the irrational price criterion block the reform.In a word,global budget will be efficient combined by changing the post -payment to prepayment and stably increasing mechanism.