上海市医疗保险总额预算管理的主要成效与问题

Effects and problems in the global budget management of health insurance in Shanghai

2002年以来,上海市医疗保险总额预算管理经历了探索期、发展期和成熟期三个阶段,主要做法包括总额预算、按月预付、分类缓付、按季结算,按季通报、半年考评,年终清算、考核和超支分担,推行"四项公开"和"三轮协商"办法等。经过改革,医疗费用增速得到有效控制,医院自我管理的积极性得到提高,进一步强化监管机制,从而为医院改革营造了良好环境,但目前的改革也面临一些问题:医疗机构内部管理不够规范,费用控制与参保人医疗需求之间矛盾突出;并且缺乏一系列有效的措施。建议从优化预算指标、强化监管、开展支付方式改革等方面进一步完善医疗保险总额预算管理。

Since 2002, the global budget management of health insurance in Shanghai has gone through three stages： exploration, development, and maturity. The main practices include global budget, prepaid by month, post- ponement of payment by categories, settling accounts by season, circulating information by season, half-yearly evalu- ation, year-end liquidation, assessment and cost overruns sharing, and the implementation of ＂giving four items pub- licity＂ and ＂three rounds of negotiation. ＂ The reforms have controlled medical expenses, encouraged hospital self- management, created a good environment for hospital reform, and strengthened the monitoring mechanism. However, there are still some problems with reform, including lack of standardization in the internal management of medical in- stitutions, contradictions between cost control and health service, and lack of effective supporting measures. We rec- ommend a three-pronged approach to perfecting global budget management： optimizing indicators, strengthening su- pervision, and developing payment reform.