医保支付方式改革推进分级诊疗的实践与成效——以玉环市人民医院健共体集团为例

Practice and effect of the reform of the payment mode of medical insurance to promote the hierarchical diagnosis and treatment:Taking the health community group of the People’s Hospital of Yuhuan as an example

玉环市自实施县域医共体建设以来,在医保部门指导下基于医保支付方式改革进行探索分级诊疗的实施路径,通过服务模式和管理模式的优化,运用医保总额预算管理、建立“结余适当留用、超支合理分担”机制、门诊病人结合家庭医生签约服务按人头包干付费、住院服务按疾病诊断相关分组(DRG)、统筹区差别化报销等政策手段,为有效促进分级诊疗制度的落地提供支撑。

Since the construction of county medical communities,Yuhuan city,under the guidance of the medical insurance department,has explored the implementation path for hierarchical diagnosis and treatment based on the reform of medical insurance payment mode.It has implemented a variety of policies to provide support for the effective promotion of hierarchical diagnosis and treatment system,which include the optimization of service mode and management mode,implementation of total budget management of medical insurance,establishment of the mechanism of“proper retention of surplus and reasonable sharing of over-expenditure”,out-patient in combination with family doctor contracted services paid on a per person basis,diagnosis related group(DRG)of in-patient services,and differential reimbursement forthe fund-pooling areas of medical insurance.