德国医保治理能力经验及借鉴

Experience and Reference of German Governance capacity of medical insurance in Germany: experience and inspiration

文章从医保制度的外部入手,将其治理能力放在"三医联动"的整体框架之下作为研究出发点。通过与德国医保治理能力的比较,力图证明改变医保在医改中的地位与作用、增强其主导治理能力,有利于医药卫生体制改革的发展,缓解"看病贵、看病难"的顽疾。同时梳理当前我国医保制度在医疗、医药、公卫等领域的治理能力现状及缺失,分析了当前医改理念、行政管理体系、医疗环境、医保自身能力等对医保主导治理能力实现的阻碍。最后,为进一步提高医保在医改中的主导治理能力,提出规范私营医疗服务市场发展,完善医疗服务市场自由竞争环境;将全科医生收入纳入医保支付范畴,实现医保对基层医疗资源配置的能力;将部分公共卫生纳入医保支付范畴,实现疾病防治的双管齐下;推进临床路径和疾病分组,推广DRGs支付方式的应用范围等政策建议。

Starting from the outside of the medical insurance system,the article puts the governance capacity under the whole framework of"Three Medical Interlocking"as the research starting point.By comparing with the governance capacity of medical insurance in Germany,the author tries to prove that the change of the position and function of medical insurance in health care reform and the strengthening of its leading governance capacity is conducive to the development of medical and health system reform and the alleviation of high cost of and difficulty in seeing a doctor.This paper also reviews the status quo and deficiency of the current medical management system from the aspects of medical treatment,pharmaceuticals,public health and so on,and analyzes the obstacles to the implementation of the leading medical governance capacity from medical reform concept,administrative system,medical environment and medical insurance itself.Finally,the paper proposes to standardize the development of private medical service market and improve the free competitive environment of medical service market,to include the income of general practitioners into the medical insurance payment system and realize the medical insurance?s allocation capacity of primary healthcare resources,to include part of the public health service charge into the medical insurance payment system and realize both prevention and control of diseases,to promote the clinical pathways and disease groups,and to expand the application scope of DRGs payment.