基于价值医疗的医疗保险支付体系改革创新

Health Insurance Payment System Based on Value-based Healthcare: Reform and Innovation

伴随我国全民医疗保险的发展,医疗保险支付体系实现对支付对象全覆盖,支付报销水平和层次得到了明显提升,支付标准逐步体现成本和质量,支付方式从单一方式转为多元复合型方式,但也存在一些亟待解决的问题。为了推动解决这些问题,有必要建立价值为导向的医疗保险支付体系。本文基于价值医疗理念下医疗服务价值的评价发展,提出建立医疗保险方与医疗服务提供方"正和竞争"的医疗保险支付制度,充分吸收医生群体的参与,采取大数据技术分析预防治疗行为,重视诊疗技术疗效评估,把健康教育和促进等健康管理行为纳入医疗保险支付目录,推进整合式医疗服务发展,发挥健康管理中个人作为"首席运营官"的作用等政策建议。

With the introduction of China’s universal health insurance,the health insurance payment system has been reformed,e.g.the benefit level significantly improved,the payment criteria began to tie to cost and quality,and a range of mixed payment methods applied.But there remain some problems.To solve these problems,it is necessary to establish a value-based health insurance payment system.Based on the evaluation of healthcare under the concept of value-based healthcare,this paper proposes to establish a"positive-sum game"of health insurance payment system between payers and providers of healthcare,fully encourage doctors participation,use big data to analyze preventive and curative behaviors,attach importance to the cost-effectiveness of medical treatment,incorporate health education and promotion into the benefit package of health insurance,promote integrated care,and pay attention to patient-reported health outcome and personal health management.