医保支付方式改革的阶段性分析研究——以深圳市罗湖医院集团为例

Stage Analysis and Research on the Reform of Medical Insurance Payment

目的统计分析罗湖"总额管理、结余奖励"医保支付方式改革试点前后医保运营相关数据,讨论医保支付方式改革的成效。方法根据行政管理权限划分,分别从医保部门、卫生计生部门、疾控中心和信息中心收集数据,对医保基金支出总额、医疗机构办医行为、居民就医行为和就医感受等方面的变化进行分析。结果改革后,医疗机构办医导向转变,控费意识增强;预防保健和分级诊疗工作取得显著成效。结论罗湖区医保支付方式改革实现了居民(患者)、医院(医生)、社保、政府的利益一致,是应该继续坚持和努力的方向。

Objective： To make the statistical analysis of data related to medical insurance operation before and after the pilot reform of medical insurance payment method of “total management and balance award” in Luohu,and discuss the effectiveness of medical insurance payment method reform.Method： The authors collected the data from medical insurance department,health and family planning department,CDC and the information center,and analyzed the changes in the total expenditure of medical insurance funds,medical institutions’ medical behaviors,residents’ medical behaviors and medical experience according to the division of administrative authority.Result： After the reform,medical institutions changed their medical guidance and increased their awareness of cost control.Significant results were achieved in preventive care and hierarchical diagnosis and treatment.Conclusion： The reform of medical insurance payment method in Luohu district has realized the unity of interests of residents （patients）,hospitals （doctors）,social security and the government,which is the direction that should be persisted,and the efforts should be made.