对“按人头付费”原理及设计的思考

Thoughts on Principles and Designing of Capitation in China

目的:本文从定义、推行改革的目的及其激励机制、主要的测算方法及在中国的应用和启示等角度对按人头付费进行了梳理。方法:测算按人头付费需要:(1)确定基金总量;(2)定义服务包;(3)计算基础按人头费率;(4)计算风险校正系数;(5)确定信息数据库;(6)计算供方的按人头预算。需要从统筹管理、财务管理、信息系统、监测系统和质量保证体系等多个角度设计按人头付费的支持体系。结果:从买方或者医保机构对按每年每位服务对象(或患者)固定的费用支付给供方这样的微观层面来讨论按人头付费,除了调配资源流向之外,大多数国家或地区实施按人头付费的主要目的是为了控制支出。结论:目前基本公共卫生服务多采用按人头付费,而在当前门诊体系推行按人头付费则存在一定的障碍。除了测算方法合适以外,要使按人头付费顺利实施,还需要制定一套机制来监督医疗卫生服务的质量。

Objective： To discuss the definition, aims of utilization and its incentives, measurement methods and application and implication in China on capitation. Methods： Estimates to pay on a per capita base need： （1） setting the fund＇s pool; （2） defining the service package ; （3） calculating the base per capita rate; （4） caleulating risk adjustment coefficients; （5） developing the enrolhnent database; （6） calculating each provider＇s per capita budget. Financial and management system information systems,monitoring systems and quality assurance system should be considered when designing the capitation＇s supporting system from multiple perspectives. Results： Capitation is usually discussed from a micro-level perspective, in addition to the deployment of resources flows, the main purpose of using capitation by most countries is cost containment. Conclusion： Currently, basic public health services are paid based on capitation, however there are certain obstacles in the current outpatient system paid per capita. In addition to the appropriate calculation methods, the implementation of capitation also needs to develop a mechanism to monitor the quality of health services.