医保总额控制下大型公立医院经营策略探讨

Discussions on the business strategy against total reimbursement control of medical insurance for large public hospitals

为解决医疗费用过快上涨、医保对供方行为约束不足、基金运行风险加剧等问题，人力资源和社会保障部等要求在统筹地区开展以总额控制为主的医保支付方式改革。总额控制对城市大型公立医院的经营管理产生了较大的影响。按照总额控制政策，提出3个层面的转型策略。在发展战略方面，转变增长方式，发挥医联体作用，增强辐射能力；在业务管理方面，确保医疗质量和安全，落实临床路径，优化服务流程；在行政管理方面，强化成本控制，加强信息化建设，转变管理职能。

To address such challenges as the rapid rise in health care costs, insufficient constraints on supply-side behavior by medical insurance, and rising risk exposure of the insurance foundation, the Ministry of Human Resources and Social Security has proposed a payment mode reform featuring total reimbursement control. Such a total control policy will affect significantly the business operation of urban public hospitals. To adapt to the impacts so incurred, a three-level transformation strategy is recommended as follows. A development strategy calling for a new growth model, greater role of hospital-health alliances for greater service coverage; a business management strategy to ensure quality of care and safety, clinical pathways in place and optimize service processes; an administrative strategy to enhance cost control, strengthen information technology, and transform the management functions.