以健康管理为导向的基层门诊慢性病按人头付费标准测算研究  

Measurement of the Capitation-based Reimbursement Standard for Chronic Disease Management in Primary Care Clinics

作　　者：倪剑潇 高广颖 赵宁[2] 李进 徐嘉杰 吴妮娜 杨佳 NI Jianxiao;GAO Guangying;ZHAO Ning;LI Jin;XU Jiajie;WU Nina;YANG Jia(Fangzhuang Community Health Service Center,Beijing 100078,China;School of Public Health,Capital Medical University,Beijing 100069,China;National Institute of Healthcare Security,Capital Medical University,Beijing 100069,China)

机构地区：[1]方庄社区卫生服务中心,北京市100078 [2]首都医科大学公共卫生学院,北京市100069 [3]首都医科大学国家医疗保障研究院,北京市100069

出　　处：《中国全科医学》2023年第19期2355-2360,共6页Chinese General Practice

基　　金：国家自然科学基金资助项目(72274129);国家医疗保障研究院开放性课题(YB2020B04,YB2020B05)。

摘　　要：背景门诊医疗服务是医保支付方式改革的重要组成部分,随着我国住院医疗服务医保支付方式改革的全面推进,门诊按人头付费、门诊病例分组(APG)点数法等多元支付方式的改革将逐步提上日程。目的本研究基于国内外不同国家和地区按人头付费的实践,以及目前北京市慢性病管理的情况,探索适合北京市慢性病按人头付费的测算方案,为北京市实施慢性病按人头付费改革提供参考。方法选择高血压、糖尿病、冠心病、脑卒中4种常见慢性病,以北京市C区和H区为例,对研究现场的医疗、医保等基本医疗数据和基本公共卫生服务经费进行分析,设计出适合所选地点的慢性病人头费标准的测算方法,并测算基层门诊主要慢性病按人头付费的标准,为推进门诊慢性病按人头付费改革提供参考。结果根据两地2017—2019年的医保数据和公共卫生经费,采用自上而下的方法,测算出H区高血压、糖尿病、冠心病、脑卒中的人头费标准分别为4693.11、6597.70、5644.46、6437.78元/人;采用自下而上的方法测算出C区高血压、糖尿病、冠心病、脑卒中人头费标准分别为4884.18、5960.63、3733.93、3886.66元/人。结论在人头费标准的测算中,不同慢性病人群门诊产生的费用不同,考虑医保的公平性和人头费的合理性,需要对基准人头费进行风险调整;针对不同种类和严重程度的慢性病制定个性化的服务包;在门诊慢性病按人头付费改革的推广中,要为不同慢性病患者提供个性化的基本医疗和公共卫生服务包,还要进一步提升社区卫生服务慢性病管理能力以提高签约率,建立有效的全科医生激励和考核机制合理分配按人头付费结余。Background The reimbursement of outpatient services is an essential part of the reform of medical insurance payment methods.With the comprehensive promotion of the reform on the medical insurance payment methods for inpatient services in China,the reform on insurance payment methods for outpatient services,such as capitation-based reimbursement and ambulatory patient groups(APG) point method,will gradually be put on the agenda.Objective To explore a capitation-based reimbursement scheme for chronic diseases applicable to Beijing based on an analysis of capitationbased reimbursement implemented in different countries and regions and the current situation of chronic disease management in Beijing,to provide a reference for implementing the capitation-based reimbursement reform for chronic diseases in Beijing.Methods This study used information related to essential medical services,reimbursement by health insurance,and essential public health service funds in Beijing's C and H districts.Then through an analysis of the information,the calculation method for capitation-based reimbursement standard for four common chronic diseases(hypertension,diabetes,coronary heart disease and stroke were selected in this study) applicable in the districts was designed to calculate the capitation-based reimbursement standard for major chronic diseases in primary outpatient clinics,providing a reference for promoting the capitation reform for chronic diseases in outpatient clinics.Results By analyzing the above-mentioned information in 2017—2019,the capitationbased reimbursement standard was 4 693.11 yuan/person for hypertension,6 597.70 yuan/person for diabetes,5 644.46yuan/person for coronary heart disease,and 6 437.78 yuan/person for stroke in H district calculated using the bottom-up costing,and was 4 884.18 yuan/person for hypertension,5 960.63 yuan/person for diabetes,3 733.93 yuan/person for coronary heart disease,and 3 886.66 yuan/person for stroke in C district calculated using the top-down estimating.Conclusion In calculati

关 键 词：全民医疗保险 卫生保健改革 慢性病 门诊医疗 人头费 健康管理 

分 类 号：R197.1[医药卫生—卫生事业管理]