我国医保差异化支付相关政策分析

Analysis of Related Policy of Differential Payment of Health Insurance in China

目的:系统分析我国医保差异化支付政策的现况,为进一步完善我国分级诊疗和相应经济杠杆刺激政策提供参考。方法:采用官方文献梳理法与综合评分法,梳理和归纳了我国32个省市(包括4个直辖市、5个自治区)颁布的医保差异化支付的相关政策。以浙江省为例,着重分析了其省内11个地市现行医保政策中差异化支付的具体改革措施,对各市的具体差异进行比较分析。结果:部分省市在分级诊疗政策出台之前就有差别化医保支付政策,但实施效果不佳。在综合评分方面以浙江省、上海市、江苏省、青海省较高(5分),重庆市、海南省、湖南省、广西、内蒙古较低(2分),此外贵州与西藏未查到相关政策文件。浙江省11个地市均已完善差异化医保支付,但差异较大。结论:差异化医保支付政策在各省实施的深浅不同,医保差异化支付标准的设定较为混乱。建议顶层设计中注重差异效果的评价,通过医保差异化建立大医院下转激励机制,制定并推广慢性病的医保差异化支付政策。

Objective： To analyze the current situation of the differential payment policies of health insurance, provide reference to further improve diagnosis of classification and corresponding economic leverage stimulus policy. Methods： Using the official literature review and comprehensive evaluation method, we summarized the related policy of differential payment of health insurance in 32 provinces of our country （including the four municipalities, five autonomous regions）. Taking Zhejiang Province as an exampie, we focused on the analysis of the concrete policies of the 11 cities in the province and made a comparative analysis of the differences between the cities. Results： Some provinces and cities had differentiated payment policy of health insurance before the hierarchical diagnosis and treatment policy but the implementation effect was not good. In terms of comprehensive scoring, Zhejiang, Shanghai, Jiangsu, Qinghai had the higher scores （5 points）, Chongqing, Hainan, Hunan, Guangxi, Inner Mongolia had the lower scores （2 points）, and the policies were not found in Guizhou and Tibet. Although 11 cities in Zhejiang Province had perfected differentiation health insurance payments, there were big difference among them. Conclusion： The implementation depth of differentiation health insurance payments policies was different and the health ＂difference＂ payment standard setting was relatively chaotic. In top level design, we should pay attention to the evaluation of the difference effect, and establish the incentive mechanism of the large hospital under the difference of health insurance, promote and establish the policy for the differential payment of chronic diseases.