责任制医疗组织医保制度对紧密型医联体建设启示

The enlightenment of the medical insurance system of the Accountable Care Organization to the construction of closely partnered Medical Cluster

美国政府推行的责任制医疗组织通过充分发挥医保利益分配机制的杠杆作用,将单个医生和医疗机构整合成紧密的利益共同体,对国内推进紧密型医联体建设具有借鉴意义。作者通过阐述责任制医疗组织的组成及特点,详细分析了其医保运行机制,总结了医保运行成效和挑战。在此基础上,为国内运用医保改革推进紧密型医联体建设进行了思考:实施医联体总额预付制,构建利益共同体;运用科学的医保控费机制,调动医疗服务供方积极性;发挥医保方对医疗质量的监管作用,保障服务效果;提供多元化的医保利益分配方案,因地制宜。

The Accountable Care Organization (ACO) promoted by the US government integrates individual doctors and medical institutions into a close interest community by giving full play to the leverage of the medical insurance benefit distribution mechanism,which has reference significance for promoting the construction of closely partnered Medical Cluster in China.By expounding the composition and characteristics of ACO,the author analyzes its medical insurance operation mechanism in detail,and summarizes the effectiveness and challenges of medical insurance operation.On this basis,the paper considers the use of medical insurance reform to promote the construction of closely partnered Medical Cluster:implement the total prepayment system of Medical Cluster to build a community of interests;use a scientific medical insurance expenditure control mechanism to mobilize the enthusiasm of medical service providers;give full play to medical insurance The regulatory role of the party on the quality of medical care,to ensure the effect of services;to provide a variety of medical insurance benefit distribution plans,according to local conditions.