福建省尤溪县医保支付方式改革及效果研究

Study of the effects of the reform on medical insurance payment model in Youxi county of Fujian province

目的:分析福建省尤溪县医保支付方式改革的措施、效果及存在问题,并提出建议。方法:通过文献研究和现场调研进行资料收集,采用统计描述和主题框架法进行分析。结果:尤溪县通过试行医联体总额预付制、持续探索完善住院费用按病种付费制度、实行差异化支付政策以及强化医保监督管理职能等,实现了医保基金运行基本平稳、医疗费用过快增长得以控制、县域内就诊率显著提升、基层服务利用逐步增加、医院收入结构得以优化、患者就医经济负担有所减轻。结论与建议:尤溪县医保支付方式改革有利于激发医疗服务提供者内生控费和质量提升动力、引导患者合理就医、保障基金安全可持续运行,但支付标准的科学性和合理性有待提升、信息化支撑作用尚未发挥到位、病案首页质量仍难以满足需求,需进行针对性完善,并同步推进其他相关领域改革。

Objective:This paper aims to analyze the measures, effects and challenges faced by the reform on medical insurance payment model in Youxi county of Fujian province, and put forward suggestions for further development.Methods:Literature review and field survey are used to collect data,and statistical description and thematic framework methods are applied to analyze the data. Results:By adopting global budget payment in medical alliances,continuously exploring and improving disease-based payment system of hospitalization expenses, implementing differentiated payment policies,strengthening the supervision and management functions of medical insurances, and so on, the operation of medical insurance fund has been basically stable, the excessive increase of medical expenses has been effectively controlled, the rates of patient visits in the county has significantly improved, the utilization of primary care has gradually increased,the income structure of hospitals has improved,and the patients' economic burden has been significantly alleviated. Conclusions and suggestions:The reform of medical insurance payment model in Youxi county helps stimulate the medical service providers' motivation for expenses control and quality improvement, guide patients to seek health care services reasonably,and ensure the safe and sustainable operation of the fund. However,there are still some problems as follows:1) the payment standards need to be more scientific and reasonable;2) the supporting role of informationization has not yet been fully played;and 3) the quality of medical record home page still cannot meet the demand. Therefore, targeted improvement should be made and reform in other areas should be deepened at the same time.