医保控费:历史源流、当前举措与优化路径——基于相关文献的综述

Medical insurance control fees: historical sources, current initiatives and optimization paths--Based on a review of relevant literature

医保第三方付费机制下控费与保质困境如一团乌云长期笼罩于医疗保险制度上空。后付制有利于保证质量但存在诱导需求、过度治疗等问题不利于控费;预付制虽有利于控费,但存在供方降低服务质量、推诿病患等缺陷。以医保控费为始点,基于相关文献分析,梳理了医保控费的历史源流和当前举措,针对目前控费措施的不足提出按绩效付费和健康管理两条优化路径,以期实现控费保质的相容,为推动健康中国建设提供可行性参考。

The third-party payment mechanism of medical insurance has a long-term control over the cost of quality control and quality, such as a cloud of dark clouds over the medical insurance system. The post-payment system is conducive to ensuring quality, but there are problems such as inducing demand and over-treatment, which are not conducive to the control fee. Although the pre-payment system is beneficial to the control fee, there are defects such as the supplier's lowering the service quality and pushing the patient. Taking the medical insurance control fee as the starting point, based on the relevant literature analysis, it sorts out the historical source and current measures of medical insurance control fees, and proposes two optimization paths of performance-based payment and health management in view of the current shortage of control measures, in order to realize the phase of charge control and quality assurance. Rong, providing a feasible reference for promoting healthy China construction.