上海市城镇职工基本医疗保险支付方式改革的历程及启示

The process and enlightenment from payment reform of the basic medical insurance for urban workers in Shanghai city

目的:全面分析上海城镇职工医保支付方式改革的历程,剖析改革诱因、暴露的问题和取得的成效,为其它地区开展相关改革提供经验借鉴。方法:收集相关文件和职工医保运行的有关数据,通过描述性统计方法进行分析,并访谈了解有关专家对上海市城镇职工医保改革的观点。结果:上海市医保支付方式改革遵循从总额控制、总额预算管理到总额预付制改革的主线,辅之以精神病医院的按床日付费、部分病种的单病种支付等精细化管理手段,改革强调多种支付方式复合使用,注重把握先易后难、逐步推进的改革步调,基本实现了筹资与支付、费用与质量的平衡。

Objective： To analyze the reform process and causes of basic medical insurance for urban workers in Shanghai （ BMIUW ） comprehensively, as well as its problems and effectiveness and to serve for the similar reforms of other areas. Methods： Policy documents and data were analyzed through descriptive statistics analysis method and expert interviews were performed to get their views. Results ： Payment reform of the BMIUW evolved from budget ceiling, budget management to global budget. It emphasized mixed use of multiple means and paid more attention to the balance of cost control and quality. The reform process followed the prescribed order and achieved the desired reform goals.