医保预付制改革能否降低医疗费用:基于医疗要素投入的视角

文章基于医疗要素投入的视角,探究我国医保预付制改革对医疗费用产生的影响效果和作用机制。通过构建包含医生的效用函数理论模型,对后付制和预付制下医疗投入要素的均衡进行求解和比较,并利用医保局124577个参保住院患者的信息进行实证检验。研究结论显示,医保支付方式由后付制转变为预付制后,患者的住院总费用下降10.17%,患者的自费金额下降27.67%,住院天数下降36.82%。从某种意义来说,后付制下供方倾向于提供过度的医疗服务并造成医疗资源的浪费,而预付制改革提供使医疗服务数量回到社会最优水平的路径,即预付制改革显著降低患者的住院总费用,其作用机制对医疗服务供方形成正向激励,具体而言是通过重构医患之间的利益格局,进而改变医生的效用函数和行为模式。基于理论和实证结果,提出相应政策建议。

医保预付制与医疗资源的节约--理论分析及上海试点的证据

基于2000—2010年上海市6家医院7个单一病种的统计数据,本文实证分析了医保预付制对医院接收病人数量、人均住院天数、人均住院费用以及人均药费等变量的影响,结果发现它能显著降低医院接收病人的数量和人均住院费用。这一结果表明:第一,医保预付制所带来的硬预算约束促使医生或医院少接收病人;第二,人均住院费用的显著下降表明医生在硬预算约束下会压缩病人的费用支出。上述结果对于我们理解医保预付制在上海市试点所产生的效果与相关政策的调整提供了有益的启示。

某院实行医保总额预付制对医疗支出的影响

目的分析医保总额预付制对医疗各项支出的影响。方法利用上海市某三级甲等综合医院2008—2010年所有单一病种住院患者的数据,应用多元回归研究医保预付制与患者的相关支出水平的关系。结果医保总额预付制减少了大型检查、普通检查和化验的数量;降低了普通检查费用、自费药品费、手术材料费、检查费、中草药费等;提高了医保药品费、住院费、诊疗费、治疗费、护理费等;总体而言,医保总额预付后,总费用却上升了6.6%。相对于自费患者,预付内患者的总费用低了4.6%。结论医保总额预付制能在一定程度上控制医疗支出,但不能统一地降低患者医保各项支出,该制度和其他配套管理措施亟需完善。

PDCA在医院医保总额预付制管理中的应用

目的:评价PDCA管理工具在医院医保实行总额预付制过程中的效果和意义。方法:运用PDCA循环法对全院各科室、各控费管理环节进行医保预付制费用管理。结果:医疗费用得到了有效控制,医保各项指标的完成情况均优于以前年度,并且控费政策执行较平稳。结论:运用PDCA法进行医院医保管理,能有效控制医疗费用增长并提高管理效能。

通过费用大类结构变化分析医保预付制对控制医疗费用的影响

目的:研究医保总量预付制前后,医院医保费用明细大类构成比例的变化情况,找出影响结构变动的主要项目,以明确在医保总量预付制条件下,合理有效控制医疗费用的可行性。方法:采取趋势变动对照法,分别统计测算出医院参加医保预付制前3年和参加医保预付制后3年的费用大类结构变化趋势,将前后趋势进行对比分析。结果:参加预付制之后,医院药品类费用占比逐年下降,手术类、治疗类费用占比逐年递增。结论:医保总量预付制促进医院降低医疗成本、优化费用结构,提高内涵质量,是有效控制医保费用过度增长和保持医院公益性的有效方法。

医保预付制能否降低医保支出？——来自长海医院试点的证据

为了探索节约公共医疗卫生资源的方法，2009年上海市的3家特大型综合医院率先在国内实行了医保预付制试点，上海市其他医院与其他省份的医院也将会陆续试行该制度，但是目前国内没有任何文献研究过该政策的实施效果及存在的问题。本文利用上海市第二军医大学附属长海医院2008—2010年所有单一病种住院病人的数据详细分析了医保预付制对预付内单一病种住院病人的各种费用的影响，并用双倍差分法（DID）识别了医保预付制对病人的相关支出水平的影响，结果发现：实施预付制后，大型检查、普通检查和化验的数量都有所下降，并且普通检查数量显著下降，下降幅度高达7．159项；对于有医疗保险的病人而言，预付制的实施能够显著降低他们的普通检查费用、自费药品费、手术材料费、检查费、中草药费和其他费用；但实施了预付制后，他们的医保药品费、住院费、诊疗费、治疗费、护理费、化验费、输氧费、西药费和中成药费均有显著上升；总体而言，后者上升的幅度超过了前者下降的幅度，因而他们支付的总费用却上升了6．6％；在实施预先付制之后，相对于自费病人，预付内病人的大型检查数量、化验数量、大型检查费用、医保药品费、住院费、治疗费、护理费、手术材料费、化验费、摄片费、西药费、中成药费、中草药费、其他费用和总费用都显著更低，总体而言，保持其他条件一致的情况下，他们的总费用比自费病人低了4．6％。

医保总额预付制下医院控费精细化管理探析

医保总额预付制下医院控费精细化管理,已成为当前医疗体系改革的重要议题。本文针对医保总额预付制下医院控费精细化管理问题进行了探讨。首先,阐述了医保总额预付制的目的和意义。接着,通过对相关文献的综述和分析,揭示了医保总额预付制下医院控费精细化管理存在的问题以及面临的挑战。并在此基础上,提出了针对性的改进建议。

浅谈医保总额预付制下的三级医院财务管理转型应对

医保总额预付制因医疗发展而备受瞩目，而财务管理以此类预付制为依据实施转型，可确保医院运行更富平稳性。特别是医院由综合性向着专科进行转型时，必须确保转型应对契合相应预付指标。本文先就医保总额预付制作基本概述，并对财务转型面临问题及其应对策略进行总结，以期为强化财务管理作出贡献。

关于深化我市医疗卫生制度改革的建议

我市自建立城镇居民基本医疗保险制度以来,已经形成了"小病有人管,大病有保障"的保障机制,但老百姓"看病难、看病贵"的状况没有根本扭转。目前,群众反映强烈的问题有5个。一是基本药物制度降低了社区卫生服务中心的药价,但部分患者买不到需要的药。全市245家社区卫生服务中心采取药品零差率销售制度,社区药价确实便宜了。但社区服务中心平均备药只有150种左右,占537种社区用药的28%。

社会医疗保障系统网络安全解决方案

医保管理系统网络安全既是公众参与管理医保安全的重要平台,又是对社会稳定造成重要影响的因素,在医保系统使用城市医保卡的用户量未来几年会突破上亿户,市民在医院看病进行实时支付,通过认证将合法用户医保部分的医药费(占总药费的75%~80%)实时从网上直接支付给医院,安全快捷,节省医药费报销审批的成本,保证财务结算安全准确。对医保安全的网络舆情研究文献按照以不同类型的與情研究对象为标准、以不同模型为标准分别进行整理、分析,并归纳这些文献的观点和策略,认为仅靠加大设备(即资金)投入来提高CA认证中心管理用户的数量只是杯水车薪,需要颠覆性的认证技术架构才能解决规模化认证面临的难题。

医保预付制改革对医院行为和医疗费用的影响研究——基于单病种定额付费的改革

全面推行以按病种付费为主的多元复合型支付方式改革是现阶段深化医改的重要任务之一。本文使用中国某副省级城市2014—2019年住院患者的数据,通过双重差分方法分析了2018年按病种付费改革对医院行为和医疗费用的影响。实证结果表明,此次预付制支付方式改革使得所覆盖的101种疾病的次均住院费用显著下降3.8%(约530元),自付费用显著下降14.4%(约230元),在一定程度上控制了医疗费用的增长,降低了患者的医疗负担。但是,试点医疗机构在财务压力下存在调整患者结构的行为,并且对非试点医院产生了溢出效应。医疗机构的策略性行为还包括改变临床路径以达到继续进行按项目付费的目的,结果显示单病种定额付费实施之后,做手术概率下降4%,合并症诊断概率增加3%。因此,政府在推进医疗保险支付方式改革过程中,应该注重规范医疗机构的行为,加强对医疗服务质量的监督管理。

医保预付制改革的效果研究——来自中国CHIRA数据的实证检验

推进医保支付方式改革是完善中国特色医疗保障制度的重要内容,对于规范医疗服务行为、引导资源配置、控制医疗费用不合理增长具有重要意义。本文利用中国医疗保险研究会2014~2017年CHIRA数据库,抽取了16个城市134522条住院患者样本,采用处理效应模型对医保预付制改革的效果进行研究。研究结果显示,医保预付制可以显著降低参保患者的住院费用,但也发现患者自付费用和住院天数有所上升。不同等级医院、不同等级城市间医保预付制控费效果存在明显的异质性,其中三级医院和一级城市控费效果最弱。进一步对医保预付制的控费机制进行研究发现,医保预付制改革存在"分配效应",医疗机构可能通过在一年不同时段分配医保额度来满足总额预付的要求。建议通过信息化手段实现区域间医保支付价格的比较,建立激励相容的医保支付机制,结合其他医保改革政策进一步积极探索多元复合支付方式。

医保总额预付制对公立医院的影响分析

医保是国家为保证社会医疗需求而建立的社会保险制度,一定程度上缓解了居民就医费用高昂的情况,为保障居民医疗需求,国家针对“就医难”“看病贵”等问题提出了医保总额预付制的结算方式。自付费方式改革以来,居民看病费用得以降低,但医保总额预付制度还不够完善,是一把双刃剑,给公立医院经营带来了利好,也带来了不利影响,居民看病难问题还未得到有效控制。文章首先对医保总额预付制进行了简单阐述,结合其特点,分析这种支付方式给公立医院带来的有利和不利影响,最后针对性地提出解决建议,以期更好地推进医保结算方式改革。

Protective effect of fufanghuangqiduogan against acute liver injury in mice

AIM: To study the effects and possible mechanisms of fufanghuangqiduogan (FFHQ) in mice with acute liver injury (ALI). METHODS: ALI was successfully induced by injecting carbon tetrachloride (CCl4) intra peritoneally and by tail vein injection of Bacillus Calmette Guerin (BCG) and lipopolysaccharide (LPS) in mice, respectively. Each of the two model groups was divided into normal group, model group, FFHQ (60, 120 and 240 mg/kg) treatment groups, and bifendate treatment group. At the end of the experiment, levels of alanine aminotransferase (ALT) and aspartate aminotransferase (AST), content of malondialdehyde (MDA), activities of superoxide dismutase (SOD) and glutathione peroxidase (GSH-px) in liver homogenate were measured by biochemical methods. The activities of tumor necrosis factor-α (TNF-α) and interleukin-1 (IL-1) were determined by radio-immunoassay. Hepatic tissue sections were stained with hematoxylin and eosin and examined under a light microscope. RESULTS: In the two models of ALI, FFHQ (60, 120, 240 mg/kg) was found to significantly decrease the serum transaminase (ALT, AST) activities. Meanwhile, FFHQ decreased MDA contents and upregulated the lower SOD and GSH-px levels in liver homogenate. Furthermore, in immunologic liver injury model, FFHQ decreased levels of TNF-α and IL-1 in serum. Histologic examination showed that FFHQ could attenuate the area and extent of necrosis, reduce the immigration of inflammatory cells. CONCLUSION: FFHQ had protective effect on liver injury induced by either CCl4 or BCG+LPS in mice, and its mechanisms were related to free radical scavenging, increasing SOD and GSH-px activities and inhibiting the production of proinflammatory mediators.

Protective effect of Weikang decoction and partial ingredients on model rat with gastric mucosa ulcer

AIM: To investigate the protective mechanisms of Weikang (WK) decoction on gastric mucosae. METHODS: Ninety rats were randomly divided into nine groups of 10 each, namely group, model group, group with large WK dosage, group with medium WK dosage, group with small WK dosage, group with herbs of jianpiyiqi (strengthening the spleen and replenishing qi), group with herbs of yangxuehuoxue (invigorating the circulation of and nourishing the blood), group with herbs of qingrejiedu (clearing away the heat-evils and toxic materials), group with colloidal bismuth pectin (CBP) capsules. According to the method adopted by Yang Xuesong, except normal control group, chronic gastric ulcer was induced with 100% acetic acid. On the sixth day after moldmaking, WK decoction was administered, respectively at doses of 20, 10 and 5 g/kg to rats of the WK groups, or the groups with herbs of jianpiyiqi, yangxuehuoxue and qingrejiedu, 10 ml/kg was separately administered to each group every day. For the group with CBP capsules, medicine was dissolved with water and doses 15 times of human therapeutic dose were administered (10 mL/kg solution containing 0.35% CBP). Rats of other groups were fed with physiological saline (10 ml/kg every day). Administration lasted for 16 d. Rats were killed on d 22 after mold making to observe changes of gastric mucosa. The mucus thickness of gastric mucosa surface was measured. Levels of epidermal growth factor (EGF) in gastric juice, nitric oxide (NO) in gastric tissue, endothelin (ET) in plasma, superoxide dismutase (SOD) in plasma, malondialdehyde (MDA) in plasma and prostaglandin I2 (PGI2) were examined. RESULTS: Compared with control group, ulceration was found in gastric mucosa of model group rats. The mucus thickness of gastric mucosa surface, the levels of EGF, NO, 6-K-PGF1α and SOD decreased significantly in the model group (EGF: 0.818±0.18 vs 2.168±0.375, NO: 0.213±0.049 vs 0.601±0.081, 6-K-PGF1α 59.7±6.3 vs 96.6±8.30, SOD: 128.6±15.0 vs 196.6±35.3, P<0.01),the levels of ET (179.96±37.40 vs 46.64±21.20, P<0.01) and MDA (48.2±4.5 vs 15.7±4.8, P<0.01) increased. Compared with model group, the thickness of regenerative mucosa increased, glandular arrangement was in order, and cystic dilative glands decreased, while the mucus thickness of gastric mucosa surface increased (20 g/kg WK: 51.3±2.9 vs 23.2±8.4,10 g/kg WK: 43.3±2.9 vs23.2±8.4,, 5 g/kg WK: 36.1±7.2 vs 23.2±8.4, jianpiyiqi: 35.4±5.6 vs 23.2±8.4, yangxuehuoxue: 33.1±8.9 vs 23.2±8.4, qingrejiedu: 31.0±8.0 vs 23.2±8.4 and CBP: 38.2±3.5 vs23.2±8.4, P<0.05-0.01). The levels of EGF (20 g/kg WK: 1.364±0.12 vs 0.818±0.18, 10 g/kg WK: 1.359±0.24 vs 0.818±0.18, 5 g/kg WK: 1.245±0.31 vs 0.818±0.18, jianpiyiqi: 1.025± 0.45 vs 0.818±0.18, yangxuehuoxue: 1.03±0.29 vs 0.818±0.18, qingrejiedu: 1.02±0.47 vs 0.818±0.18 and CBP: 1.237±0.20 VS 0.818±0.18, p<0.05-0.01), NO (20 g/kg WK: 0.480±0.026 vs 0.213±0.049, 10 g/kg WK: 0.390±0.055 vs 0.213±0.049, 5 g/kg WK: 0.394±0.026 vs 0.213±0.049, jianpiyiqi: 0.393±0.123 vs 0.213±0.049, yangxuehuoxue: 0.463±0.077 vs 0.213±0.049, qingrejiedu: 0.382±0.082 vs 50.213±0.049 and CBP: 0.395±0.053 vs 0.213±0.049, P<0.05-0.01), 6-K-PGF1α (20 g/kg WK: 86.8±7.6 vs 59.7±6.3,10 g/kg WK: 77.9±7.0 vs 59.7±6.3, 5 g/kg WK: 70.0±5.4 vs 59.7±6.3, jianpiyiqi: 73.5±12.2 vs 59.7±6.3, yangxuehuoxue: 65.1±5,3 vs 59.7±6.3, qingrejiedu: 76.9±14.6 vs 59.7±6.3,and CBP: 93.7±10.7 vs 59.7±6.3, P<0.05-0.01) and SOD (20 g/kg WK: 186.4±19.9 vs 128.6±15.0,10 g/kg WK: 168.2±21.7 vs 128.6±15.0, 5 g/kg WK: 155.6±21.6 vs 128.6±15.0, jianpiyiqi: 168.0±85.3 vs 128.6±15.0, yangxuehuoxue: 165.0±34.0 vs 128.6±15.0, qingrejiedu: 168.2±24.9 vs 128.6±15.0, and CBP: 156.3±18.1 vs 128.6±15.0, P<0.05-0.01) significantly increased. The levels of ET (20 g/kg WK: 81.30± 17.20 vs 179.96±37.40, 10 g/kg WK: 83.40±25.90 vs 179.96±37.40, 5 g/kg WK: 93.87±20.70 vs 179.96±37.40, jianpiyiqi: 130.67±43.66 vs 179.96±37.40, yangxuehuoxue: 115.88±34.09 vs 179.96±37.40, qingrejiedu: 108.22±36.97 vs 179.96±37.40, and CBP: 91.96±19.0 vs 179.96±37.40, P<0.01) and MDA (20 g/kg WK: 21.6±7.4 vs 48.2±4.5, 10 g/kg WK: 32.2±7.3 vs 48.2±4.5, 5 g/kg WK: 34.2±6.2 vs 48.2±4.5, jianpiyiqi: 34.9±13.8 vs 48.2±4.5, yangxuehuoxue: 35.5±16.7 vs 48.2±4.5, qingrejiedu: 42.2±17.6 vs 48.2±4.5, and CBP: 30.1±6.1 vs 48.2±4.5, P<0.05-0.01) obviously decreased. The 20 g/kg WK group was better than 10 g/kg (the mucus thickness: 51.3±2.9 vs 43.3±2.9, NO: 0.480±0.026 vs 0.390±0.055, SOD: 186.4±19.9 vs 168,2±21.7, P<0.01) and 5 g/kg (the mucus thickness: 51.3±2.9 vs36.1±7.2, NO: 0.480±0.026 vs0.394±0.026, SOD: 186.4±19.9 vs155.6±21.6, P<0.01) groups and CBP group (the mucus thickness: 51.3±2.9 vs 38.2±3.5, NO: 0.480±0.026 vs 0.395±0.053, SOD: 186.4±19.9 vs 156.3±18.1, P<0.01) in the mucus thickness, NO and SOD levels and better than 10 g/kg (86.8±7.6 vs 77.9±7.0, P<0.05) and 5 g/kg (86.8±7.6 vs 70.0±5.4,P<0.05) groups in 6-K-PGF1α level, 10 g/kg WK group was better than 5 g/kg WK (the mucus thickness: 43.3±2.9 vs 36.1±7.2, P<0.01, SOD: 168.2±21.7 vs 155.6±21.6, P<0.05) and CBP groups (the mucus thickness: 43.3±2.9 vs 38.2±3.5, P<0.01, SOD: 168.2±21.7 vs 156.3±18.1, P<0.05) in the mucus thickness and SOD level. In compound group, jianpiyiqi group, yangxuehuoxue group, qingrejiedu group, the level of ET was decreased, NO contents were increased in gastric tissue of ulcers in rats. CONCLUSION: WK decoction and separated recipes have significantly protective effect on ethanol-induced gastric mucosal injury. They can increase the content of EGF in gastric juice, PGI2 SOD in plasma and NO in gastric tissues, thicken the mucus on the gastric mucosa, and decrease the impairing factor MDA, ET in plasma.

Research of great sickness assistance and protection mechanism

In recent years, with the national attention on health, increasing medical needs, rising health care costs, public voice rising, more and more health care problems to our community. Many new problems should be solved, it is necessary to conduct in-depth research. This article aims to explore the great sickness Medicaid reasonable path, intended to establish a stable great sicknesss relief and protection mechanism.

The study of basic medical insurance system for urban residents in China

The basic medical insurance system for urban residents is an important part of China＇s social security system.This article analyzes the problems which existing in the basic medical insurance system for urban residents and puts forward the corresponding countermeasures.

Reference of retirement system in developed country from the Chinese pension system constitutes

The Chinese government attaches great importance to the social security system, and makes it as an important pillar of socialist market economic system. Especially in the last decade, we seize the sustained, rapid and healthy development of the favorable opportunity of the construction of social security system; we have made unremitting efforts and achieved important progress. After years of exploration and practice, we have a clear basic principles of the social security system and the overall objectives and major tasks, we also established social pooling and individual accounts of the basic old-age insurance, basic medical insurance system, covering pension, medical, unemployment, work injury and maternity insurance, the urban minimum living security system and the framework of the social security system basically forms. The coverage of social insurance continuously expands social security funds which are through nmltiple channels to raise the initial formation mechanism forms, the level of protection continuously improves, and management and service system also gradually improves. The social security system＇ s reform and development plays a very important role in ensuring the basic livelihood of the people, the state-owned enterprise reform, and the smooth progress of economic restructuring.

Research on social medical insurance of migrant workers --A case of Suqian city in Jiangsu province

City migrant workers, as one part of the city＇s development, economic development and other aspects of urban to make a great contribution, but the delay with the local residents do not enjoy the same level of medical care treatment is always blocked in outside the city＇s health care system, have less relevant departments, there is no practical system introduced regulations and policies, these things tell us to pay attention to the people, and the introduction of appropriate medical insurance of migrant workers possibly things, and timely medical security system of such groups and the local people medical protection for long support. Make medical insurance system can cities try it＇s best to help foreign workers Medicare, Medicare for the development of China has made a modest contribution.

A Thought About the Integration of Urban and Rural Medicare

Presently, Chinese urban and rural medicare systems differ from each other in many aspects including coverage, payment, and funding patterns, etc, which accounting mainly for the serious situation of the division between urban and rural areas, among different areas and among different communities. The paper will firstly illustrate the purposes and principles of integrating urban and turn/medical insurance systems. Then, with the development of socialist core value--equity, the consideration of the development of the social security system, and the consideration of the strengthening of the rural and urban economy, integrating three main basic health insurance systems is required to take place urgently, In the last part, it provides the strategic development of the inter,ration of the dual svstem.so as to build an uniform social insurance system.