全科医生按人头医保全口径预付管理方案的模式架构探讨  

Pattern and Framework of the Management Plan of Full-caliber Health Insurance Prepayment Managed by General Practitioners According to the Number of Patients

作　　者：戴慧敏[1] 寿涓[2] 成园 杜兆辉 

机构地区：[1]上海市浦东新区潍坊社区卫生服务中心,200122 [2]复旦大学附属中山医院全科医学科

出　　处：《中国全科医学》2015年第29期3533-3536,共4页Chinese General Practice

基　　金：上海市浦东新区卫生与计划生育委员会社区卫生项目(PW2014C-26);上海市浦东新区卫生系统重点团队建设资助项目(PWZq2013-11)

摘　　要：目的针对总额预付制度下,政府确定合理医保总额难度大的问题以及医疗机构存在少收医保患者、降低服务质量等现象,探索全科医生按人头医保全口径预付管理方案的模式架构。方法本研究采用理论研究与实证研究相结合的方法,通过借鉴国外成熟的医保费用控制经验和理论及充分吸收国内研究机构的相关研究成果,探索适合我国国情和医疗卫生发展需要的合理控制医保费用的方法和措施。结果拟建立起以主要在社区卫生服务中心就诊的签约居民为预付对象,以签约全科医生为责任人,以社区临床路径为管理工具,以疾病控制达标率、成本管理合理性和签约对象满意度为判断标准的按人头医保全口径预付管理方案,形成符合客观现实的模式架构。结论可尝试通过全科医生家庭签约服务制,按人头医保全口径预付管理,实现全科医生"守健康、守费用",使其真正成为社区居民健康的守门人。此模式尚不成熟,还需实践进一步证实。Objective To explore the pattern and framework of the management plan of full-caliber health insurance prepayment plan managed by general practitioners according to the number of patients, in order to provide solutions for the problems like difficulty of government in determining the total amount of health insurance,the reluctance of medical settings to admit patients with health insurance and poor service quality of medical settings for patients with health insurance. Methods In this study,we adopted the combination of theoretical research and empirical research method. Through referencing the foreign experience of health insurance cost control and absorbing the research results of domestic research institutions, we explore methods and measures for the reasonable control of health insurance cost appropriate for China＇s national condition and the needs of health development. Results A management plan of full-caliber health insurance prepayment by the number of patients was built,with the signed residents who received treatment in community health service centers as prepayment objects,signed general practitioners as persons in charge, community clinical pathway as management tool, and with the standard-reaching rate of disease control,the rationality of cost management and the satisfaction degree of patients as criteria,thus a mode according with objective reality was formed. Conclusion Health insurance full-caliber prepayment by the number of patients under GP contract-signing family service system can be tried, so as to make general practitioners become the real gatekeepers of community health services. However,the mode is not mature yet,which needs further verification.

关 键 词：全科医生 保险 长期医疗 预付费卫生计划 费用控制 

分 类 号：R197[医药卫生—卫生事业管理]