我国总额预算下门诊按人头付费的模式演变、关键问题及路径优化  

The Evolution Process,Key Issues and Path Optimization of Blended Global Budget and Capitation for Outpatient Insurance in China

作　　者：谭华伟 张培林[1] 皮星 程伟[1] 张云[1] 陈迎春[2] TAN Hua-wei;ZHANG Pei-lin;PI Xing;CHEN Ying-chun(The Ninth People’s Hospital of Chongqing,Chongqing,400700,China;Tongji Medical College,Huazhong University of Science&Technology,Wuhan,400030,China;不详)

机构地区：[1]重庆市第九人民医院,重庆400700 [2]华中科技大学同济医学院医药卫生管理学院,武汉430030

出　　处：《中国卫生经济》2021年第12期20-25,共6页Chinese Health Economics

基　　金：重庆市社会科学规划项目(2020YBGL98、2019YBJJ033);重庆市制度创新项目(cstc2020jsyj-zzysbAX0043);四川医事卫生法治研究中心课题(YF20-Q14);北碚区科委制度创新项目(2020-37)。

摘　　要：医保支付制度改革是门诊统筹实现高质量发展的关键点和突破点,总额预算下按人头付费常视为门诊统筹最有效的支付方式。文章在收集整理政策文本的基础上,将我国总额预算下按人头付费演变历程划分为起步阶段、创新发展早期、创新发展中期、创新发展后期4个阶段,并归纳各阶段的政策要素特征。在此基础上,从功能定位、签约管理、风险调整、质量与绩效考核4个方面梳理我国总额预算下按人头付费发展的关键制约问题,最后提出以门诊疾病分组和病组点值为工具促进门诊统筹"保费用"和"保疾病"的有效融合、创新定点机构管理手段、健全多维因素的风险调整机制、健全以健康结果为导向的质量评价和结果运用机制4个可能的优化路径。Payment system reform is the key point and outbreak of realizing high-quality development for outpatient planning.Capitation of outpatient is the most effective payment for outpatient planning under the global budget.Based on summarizing policy text of payment method for outpatient insurance,the evolution process of blended global budget and capitation for outpatient insurance is divided into primary stage,early stage for innovation development,meddle stage for innovation development and last stage for innovation development.The characteristics of key policy factors in different stages are summarized.The key issues which limit development of blended global budget and capitation for outpatient insurance were summarized,including functional positioning,contract management,risk adjustment,quality and performance assessment.Finally,it proposed the path optimization of using outpatient disease grouping and disease group value as the tools to improve the effective integration of"insurance by cost"and"insurance by disease"under outpatient planning,innovate the management measurement for the pilot institutions,implement the risk adjustment machnism for multi-factors,complete the health result guided mechanism for quality evaluation and result operation.

关 键 词：医疗保障 总额预算 按人头付费 门诊统筹 模式演变 优化路径 

分 类 号：R1-9[医药卫生—公共卫生与预防医学] F840.613[经济管理—保险]