我国县域医疗卫生共同体医保总额付费运行现状分析

Analysis of the Current Situation of the Total Payment of Medical Insurance in China’s County Medical Complex

医保付费方式的深化改革是促进医疗卫生共同体高质量发展的核心,是撬动分级诊疗的重要杠杆,而总额预付制是目前正在积极探索的医保付费方式。根据对典型地区医疗卫生共同体医保付费方式进行梳理,发现总额预付制具有控制医疗成本、优化收入结构、促进合理就医、保证医保平稳运行、减轻患者负担等优点,但其核定标准缺乏合理性、监督机制尚不完善、信息系统支撑不足、引发道德风险等问题阻碍了其有效推进,为医疗卫生共同体的高质量发展带来阻力,亟待解决。

The core of the high-quality development of the county medical complex is the deepening reform of the medical insurance payment method,is an important lever for leveraging graded diagnosis and treatment.The total prepayment system is currently being actively explored for medical insurance payment methods.It sorts out the medical insurance payment methods of typical medical communities and finds that the total prepayment system has the advantages of controlling medical costs,optimizing the revenue structure,promoting rational access to medical care,ensuring the smooth operation of medical insurance,standardizing medical behavior,and reducing the burden on patients.However,the lack of rationality of its approved standards,imperfect supervision mechanism,insufficient information system support,and moral hazard have hindered its effective advancement and brought resistance to the high-quality development of the county medical complex,which needs to be resolved.