上海市医保总额预付制试点三级医院医疗服务行为变化研究

Research on the effect of global budgeting in social health insurance on the tertiary hospitals in Shanghai

目的:评估实施医保总额预付制试点三级医院医疗服务行为的变化,并提出相应建议。方法:通过定性访谈、问卷调查、上海医联平台数据统计等收集资料,进行统计分析和理论分析。结果:临床医师感受到控费压力加大,部分临床医师调整了对医保患者的用药行为;各批次三级医院的医疗费用增长和药品费用增长得到控制,医保患者的药品费用结构发生变化。结论:实施医保总额预付制试点医院的临床服务行为有一定程度改变,这些变化以减少过度医疗为主,控制费用增长的作用已经初显。建议制定相对合理的医保额度,并引导和鼓励三级医院加强医保管理。

Objectives:To find the changes of tertiary hospitals’ service delivery behavior and provide suggestion for further policy improvement. Methods:Qualitative interview, questionnaire survey and database statistics were conducted. Results:Clinicians felt the pressures of cost control. Most clinicians changed the behavior of service delivery for the insured patients. Statistics show that the growth of medical expenses had been under control and the structures of the insured patients’ drug fee changes. Conclusion:The behavior of services delivery in tertiary hospitals for the insured patients have changed by global budegt policy. The excessive medical treatments are reducing and cost growths are slowing down. We suggest that the setting of budgeting should be more reasonable and tertiary hospitals should be guided and encouraged to strengthen the management of healthcare expenditure.