整合医疗服务质量的医保创新支付设计探讨  

Innovative Payment Design of Medical Insurance Based on Healthcare Quality Integrated

作　　者：张研[1] Zhang Yan(School of Medicine and Health Management,Huazhong University of Science&Technology,Wuhan,430030)

机构地区：[1]华中科技大学同济医学院医药卫生管理学院,武汉430030

出　　处：《中国医疗保险》2020年第7期8-12,共5页China Health Insurance

基　　金：国家自然科学基金面上项目:基于信息技术的农村地区医疗高费用人群识别与整合服务供给模式研究(基金编号:71974046)。

摘　　要：医疗保障体系与医疗服务供给体系间的结构性摩擦引发患者医疗服务利用无序、参保人疾病经济负担居高不下。由于自由择医政策下参保患者需自行承担因就诊机构选择失误而带来的经济与健康风险,进而倾向选择高级别医疗机构就诊。应考虑设计基于结局风险分担的医保创新支付,通过衔接服务质量与费用支付,推动医疗-医保的价值共创,引导患者基层首诊。医保的支付改革应整合医疗服务质量,从保险业务管理提升到健康服务体系治理,开展基于结局风险分担的甄别性支付,重点探索特定情境下的按绩效支付方式。The structural friction between the healthcare insurance system and the medical delivery system has led to chaotic healthcare utilization and high economic burden on residents.Due to the policy of free choice of medical treatment,patients bear coming economic and health risks because of a fault choice on medical institution,then they tend to choose high-level medical institutions.The innovative payment of healthcare insurance based on the outcome risk sharing connects quality and cost,which can promote the value co-creation and guide residents to primary consult at the grass-roots level.The payment reform of medical insurance should integrate the quality of healthcare,switch business management to health governance,carry out discriminatory payments based on risk sharing of outcomes,and focus on exploring performance-based payment methods in specifi c situations.

关 键 词：支付方式 分级诊疗 服务协作 创新支付 按绩效付费 

分 类 号：F840.684[经济管理—保险] C913.7[社会学]