县域医共体模式下医保基金支付管理现状调查  

Research on the Medical Insurance Fund Management Situation Under the Model of County Medical Community

作　　者：刘昭 孙志成 赵琨 申斗 冯世强 刘跃华 LIU Zhao;SUN Zhi-cheng;ZHAO Kun(China National Health Development Research Centre,Beijing,100191,China)

机构地区：[1]国家卫生健康委卫生发展研究中心,北京100191 [2]清华大学医院管理研究院,广东深圳518055 [3]北京大学中国卫生经济研究中心,北京100080 [4]龙岩紫荆创新研究院,福建龙岩364000

出　　处：《中国医院管理》2021年第8期58-62,共5页Chinese Hospital Management

摘　　要：目的分析县域医共体医保支付管理现状,并提出相关政策建议,以期为县域医共体医保支付方式改革提供参考依据。方法采用问卷调研方法收集基础信息。采用描述性分析对县级医院医保基金支付管理现状进行统计描述,采用卡方检验探索不同县级医院间医保管理机制差异。结果 2016—2019年,多元复合支付方式为样本医院主流医保支付方式。80%以上的样本医院医保总额有所增加,按月拨付及按季度拨付为医保基金拨付的主要方式。60%以上的样本医院已建立医保谈判协商机制、支付动态调整机制,样本医院医保预算额度分配权多归属于医保经办机构。结论现有医保资金及财政资金分配权力与责任界限尚需明确;医保基金总额预算方法有待改进;DRG与个人账户改革等政策引入带来新的挑战。建议设计激励相容的医保基金分配方式,提高统筹层次、科学优化医保基金总额测算与支付制度,以基金监管为指挥棒,全面提升医共体服务质量。Objective To analyze the current status of medical insurance payment management in the county medical community in China,and put forward relevant policy recommendations,in order to provide a reference for the reform of the county medical community medical insurance payment method.Methods Questionnaire survey was used to collect basic information.Descriptive statistical methods were used to statistically describe the current status of medical insurance fund management in county-level hospitals.Chi-square test was used to explore the differences in medical insurance management mechanisms among different county-level hospitals.Results The multiple payment methods are combined as the mainstream medical insurance payment methods in the sample hospital from 2016 to2019.More than 80%of the sample hospitals’total medical insurance increases,and the main method of payment are monthly and quarterly payment for medical insurance.More than 60%sample hospitals have established a medical insurance negotiation mechanism and a dynamic payment adjustment mechanism.Most of the sample hospital’s medical insurance budget quota allocation right belongs to the medical insurance agency.Conclusion The boundary of authority and responsibility for the allocation of medical insurance funds and financial funds need to be clarified.The global budget method of medical insurance funds needs improvement.The introduction of new policies,such as Diagnosis Related Groups and personal account reform,brings new challenges.It is suggested to design an incentive-compatible medical insurance fund distribution method,upgrade the budget fund coordination level,scientifically optimize the total calculation and payment system of the medical insurance fund,and use fund supervision as the baton to comprehensively improve the service quality of the medical community.

关 键 词：县域医共体 医保支付方式 总额预付 激励机制 

分 类 号：R197.1[医药卫生—卫生事业管理]