国内外医保基金总额预算管理模式分析

Analysis of total budget management models of medical insurance funds at home and abroad

总额预算制能有计划地将医疗费用控制在预算范围内,是国内外普遍采用的医保基金结算方式。本研究以英国英格兰地区及我国台湾地区和福建省三明市的医保总额预算模式为例,介绍了总额预算相关管理形式、考量因素和测算方法等。英国英格兰地区从医疗服务的"需求侧"出发,以加权人口数为测算基础,将需求和成本因素测纳入测算,对医疗服务进行分类测算,参与预算的人员包括全科医生、管理人员和公共卫生专家等。我国台湾地区和三明市均从医疗服务的"供给侧"出发,以上一年度医疗服务结算金额为测算基础,其中,台湾地区将非协商因素、协商因素和付费者意愿等纳入测算,对医疗机构进行分类测算,参与预算的人员主要为医院代表、参保人员代表和专家学者等;三明市将参保人数、民众就医需求和物价变动等因素纳入测算,对城镇职工医保和城乡居民医保进行分类测算,参与预算的人员主要为医保管理部门和医疗机构代表。总体来看,英格兰地区医保基金总额预算的测算过程较精细,参与预算的各方代表较多。目前,我国内地地区的医保基金总额预算的测算指导框架和测算过程有待进一步完善,且相关信息公开程度及参与人员代表性还需提升,建议进一步加强顶层设计,完善总额预算指导框架;从需求角度出发,发展第三方专业测算机构;推动测算过程公开化,优化参与人员构成,以期提升我国医保基金总额预算的科学性。

The total budget system can systematically control medical costs within the budget,which is a commonly settlement method for medical insurance funds at home and abroad.This study introduced the forms of management,considerations and calculation of the total budget models of medical insurance in England of UK as well as Taiwan and Sanming City of China.England of UK started from the"demand side"of medical services,using weighted population as the calculation basis,incorporating demand and cost factors into the consideration,and classifying medical services for calculation.The personnel participating in this budget include general practitioners,managers,and public health experts,etc.Both Taiwan and Sanming City in China started from the"supply side"of medical services,and chose the previous year′s medical service settlement amount as the calculation basis.Among them,the Taiwan region put non negotiation factors,negotiation factors,willingness of payers,etc into consideration,and classified medical institutions for calculation,with hospital representatives,insured personnel representatives,and experts and scholars involved in the budget process;Sanming City put factors such as the number of insured individuals,the demand for medical treatment from the public,changes in prices,etc into consideration,and classified urban employee medical insurance and urban and rural resident medical insurance for calculation,with the representatives of medical insurance management departments and medical institutions involved in the budget process.In general,the process of calculating the total budget of the medical insurance fund in England was more elaborate,with more representatives involved in the budget.At present,the calculation guidance framework and process of the total budget of medical insurance funds in Chinese Mainland needed to be further improved,and the degree of disclosure of relevant information and the representativeness of participants needed to be promoted.This study suggested that medical insurance fund management of China should further strengthen the top-level design and improve the budget guidance framework,develop a third-party professional calculation agency from the perspective of demand,promote the openness of the process and optimize the composition of the participants,to enhance the scientificity of the total budget of medical insurance fund of China.