基于价值医疗视角的医保管理实践——以上海某三甲医院为例

Medical Insurance Management Practice Based On The Perspective Of Value Medicine——Taking A Tertiary Hospital In Shanghai As An Example

价值医疗是指如何在一定成本下获得最佳的治疗效果,其核心是以患者需求为中心,倡导从传统医疗服务向"以人为本的一体化服务"转型。在具体实践中,价值医疗将有助于达成医疗服务供给侧和需求侧的平衡,实现医保支付方、医疗服务提供方和患者方的多方共赢,契合我国全民医保制度下医保支付的价值目标。本文基于价值医疗视角,以上海市某三甲医院为例,探索总额控制背景下医保管理策略及实践,达到合理控制医疗成本、提高医疗质量和患者满意度的平衡。

Value-based medicine refers to the best therapeutic effect at a certain cost in accordance with patients’needs,and advocates the strategic transformation from traditional medical services to"people-oriented integrated services"(PCIC).In specific practice,value-based medicine will realize the balance of supply-side and demand-side interests,and achieves a win-win situation for payer,physician,provider and patient,that is in conformance with the medical insurance payment management of China.Based on the perspective of valuebased medicine,this paper takes a tertiary hospital in Shanghai as an example to explore the medical insurance management strategy and practice under the background of total amount control,so as to achieve the balance of reasonable control of medical cost,improvement of medical quality and patient satisfaction.