我国部分地区医联体医保总额预付制改革的比较分析

Comparative Study on Global Budget Reform of Regional Health Alliance in China

目的了解我国部分典型地区医联体模式下医保总额预付制度改革的做法及实践中存在的问题。方法采用内容分析法对深圳罗湖、安徽天长、福建尤溪、浙江德清等地医保总额预付制的预付层次、复合支付方式改革、预付标的范围、预付水平设定、结算机制和监督考核等方面的做法进行梳理和深入分析。结果各地区域医联体以人群为总额预算管理单位,对单个供方实行按病种付费、DRG等复合支付方式改革,预付标的范围为医保基金支付费用总额,预付水平主要基于上年度医保基金支出增长、当年医保基金筹资水平或增长率和支出增长率等确定。结论以医联体为单位的总额预付制对供方行为的影响取决于不同管理要素产生的激励约束机制的协同作用,以区域医联体为单位的总额预付制有助于实现整合医疗卫生服务,与国际上基于价值的医保支付制度仍存在一定差距。

Objective To understand the practices and problems of global budget reform of regional health alliance in partial priority areas.Methods Content analysis was used to analyze each element of global budgeting process in Luohu of Shenzhen,Tianchang of Anhui,Youxi of Fujian,Deqing of Zhejiang,etc.Results Regional health alliance took population as payment unit,and case-based payment and DRG were applied to single provider.Prepayment scope was total amount paid by medical insurance,budget was set based on historical and capitation approach.Conclusion The impact of regional health alliance global budget on health care provider depends on synergy incentive and restraint of different elements.Global budget based on regional health alliance contributes to achieve integrated health care system.There is still big disparity compared with valued-based payment.