预付费方式下医疗质量的四种保障路径  

Discussing the four paths to ensure the quality of medical service in prepaid medical insurance system

作　　者：赵云[1] 吴琪俊[2] 

机构地区：[1]右江民族医学院公共卫生与管理学院,广西百色533000 [2]广西中医药大学公共卫生学院

出　　处：《中国卫生事业管理》2015年第6期412-415,共4页Chinese Health Service Management

基　　金：国家自然科学基金项目"基层医疗体制机制与医疗保险付费方式的适配性研究"(编号:71463060);教育部人文社会科学研究项目"公立医院体制机制与医疗保险付费方式的适配性研究"(编号:13YJCZH271);广西高等学校人文社会科学研究项目"县级公立医院长效补偿机制的创构基于医疗保险付费制度的研究"(编号:SK13YB074)

摘　　要：医疗保险的预付费方式既具有控制医疗费用的优势,也存在降低医疗质量的缺陷。如何在控制医疗费用的同时不降低医疗质量,主要有四种途径,一是要求医疗机构实施临床路径,二是优化医疗保险预付费标准,三是构建医疗服务质量监控体系,四是营造医疗质量风险治理机制。其中,第四种办法搭配第二种办法效果最优,是预付费方式下保障医疗质量的根本途径,适合管办分开的医院体制和供给竞争的医疗体制;第三种办法搭配第一种办法效果次优,是预付费方式下保障医疗质量的权宜策略,适合管办不分的医院体制和公立垄断的医疗体制。Medical insurance prepaid mode has the advantage of controlling medical expense, but has the defect of lowering the quality of medical treatment. To control medical expenses without lowering medical quality, there have four pathways. One is to implement clinical pathway. The second is to optimize prepaid standard. The third is to construct monitoring system of medical serv- ices quality. And the fourth is to establish risk control mechanism. Among these four pathways, the optimal combination is the sec- ond pathway combined with the fourth, which is important to ensure medical services quality. And the combination of the third path- way with the first is an expedient to meet existed system.

关 键 词：医疗保险 预付费方式 医疗服务质量 保障路径 

分 类 号：R197.1[医药卫生—卫生事业管理]