差异化医保报销政策对患者就医行为引导作用研究  

Research on the guiding effect of differentiated reimbursement policy on patients’ medical behavior

作　　者：田怀谷[1] 刘晓彩 汪文新 陈芸[1] TIAN Huaigu;LIU Xiaocai;WANG Wenxin;CHEN Yun(Shenzhen Hospital of Peking University,Shenzhen,Guangdong Province,518036,PRC;不详)

机构地区：[1]北京大学深圳医院,广东省深圳市518036 [2]汕头大学法学院汕头大学法学院公共管理系/汕头大学地方政府发展研究所,广东省汕头市515063 [3]汕头大学法学院/汕头大学地方政府发展研究所,广东省汕头市515063

出　　处：《中国医院》2022年第6期10-12,共3页Chinese Hospitals

基　　金：国家自然科学基金资助项目(71673121);广东省自然科学基金项目(2021A1515011599)。

摘　　要：分级诊疗体系建设作为医疗卫生体制改革的关键一环,与差异化医保报销政策相互作用、相辅相成。事实证明,差异化医保报销政策在刺激居民医疗需求行为、引导患者就医流向方面有一定效果,但不同病种、年龄、城乡之间的作用效果存在差异。究其原因,医疗服务的刚需性、患者的就医惯性、城乡基层医疗机构的薄弱性同样影响患者就医流向,限制了差异化医保报销政策的引导作用。为更好地发挥这一政策对分级诊疗体系的推进作用,引导患者形成合理的就医行为,需增强政策宣传、提高居民对医保政策的理解与执行及形成适度医疗的健康观念。同时,引导优质医疗资源下沉以提升城乡基层医疗机构首诊率,建立医疗机构利益共同体以减少各级医疗机构间利益纷争。As a key part of China’s medical and health system reform,Hierarchical Medical System interacts with and complements the differentiated medical insurance reimbursement policy.Facts have proved that differentiated medical insurance reimbursement policies have certain effects on stimulating residents’ medical demand behavior and guiding patients’ medical treatment flow,but there are differences among different diseases,ages and urban and rural areas.The reason is that the rigid demand for medical services,the inertia of patients seeking medical treatment,and the weakness of urban and rural primary medical institutions also affect the flow of patients seeking medical treatment,limiting the guiding role of differentiated medical insurance reimbursement policy.In order to give full play to the promoting role of this policy on the Hierarchical Medical System and guide patients to form reasonable medical treatment behaviors,it is necessary to strengthen policy publicity,improve residents’ understanding and implementation of medical insurance policy,and form a healthy concept of moderate medical treatment.At the same time,high-quality medical resources should be guided to sink to improve the first diagnosis rate of urban and rural primary medical institutions,and the interest community of medical institutions should be established to reduce interest disputes among medical institutions at all levels.

关 键 词：差异化 医保报销 分级诊疗 就医行为 适度医疗 医疗保险 

分 类 号：R197.3[医药卫生—卫生事业管理]