通过医保支付推进医疗质量管理的经验及启示

Experience and Inspiration of Medical Insurance Payment for Promoting Medical Quality Management

目的通过介绍典型国家及地区经验,阐述医保如何通过经济手段促进医疗服务质量提升,供我国大陆地区参考。方法采用文献分析法。采取主题词与分类号组合的检索方式,收集美国、英国及我国台湾地区有关医保与医疗服务质量的文献。结果美国实行基于价值支付的奖惩机制,包括医院服务价值购买计划、再入院扣费计划、医院获得性疾病扣费计划;英国实行提升基层医疗服务质量的激励机制;我国台湾地区实行结合医院评价体系的总额预付制。结论为促使我国大陆地区通过医保支付进一步推进医疗质量管理,建议建设卫生主管部门与医保部门有机融合的医疗质量考核系统,采用质量指标的多元计分方式,设计与质量联动的奖惩机制等。

Objective To introduce the experience of typical countries and regions,and describe how medical insurance promotes the quality of medical service through economic means,for reference in China's Mainland.Methods Literature review method was used.The literatures related to medical insurance and medical service quality in the United States,the United Kingdom,and Taiwan of China were collected by using the combination of keywords and classification numbers.Results The reward and punishment mechanism based on value payment was implemented in the United States,including hospital service value purchase plan,readmission deduction plan and hospital acquired disease deduction plan.The United Kingdom implemented the incentive mechanism to improve the quality of primary medical service.The total advance payment system combined with hospital evaluation system was implemented in Taiwan of China.Conclusion In order to further promote medical quality management in China's Mainland through medical insurance payment,it is suggested to build an organic integration of medical quality assessment system between health authorities and medical insurance departments,develop multiple scoring methods of quality indicators,and design a reward and punishment mechanism linked with quality.