中国医疗保险主要付费方式改革进程研究  

Research on the Reform Process of the Main Payment Methods of Medical Insurance in China

作　　者：李佳艺 顾民 LI Jia-yi;GU Min(Administrative Office of Sir Run Run Hospital,Nanjing Medical University,Nanjing 210000,Jiangsu,China;School of Public Health,Nanjing Medical University,Nanjing 210000,Jiangsu,China;Department of Urinary Surgery,the Second Affiliated Hospital of Nanjing Medical University,Nanjing 210000,Jiangsu,China)

机构地区：[1]南京医科大学附属逸夫医院行政办公室,江苏南京210000 [2]南京医科大学公共卫生学院,江苏南京210000 [3]南京医科大学第二附属医院泌尿外科,江苏南京210000

出　　处：《医学信息》2023年第21期188-192,共5页Journal of Medical Information

摘　　要：随着全民医保制度不断完善,传统的医疗保险支付方式——总额预付、按项目预付等已经难以满足现代医疗卫生事业的发展,也不利于医保基金的管理。各地积极探索医保支付方式改革,在保障参保人员权益、控制医保基金不合理支出等方面均取得了积极成效。然而医保管理对医疗服务双方,特别是提供方的引导制约作用尚未得到有效发挥。本文主要比较了按服务项目支付、按服务单元付费、按人头支付、总额预付、疾病诊断相关分组、基于大数据的病种分值付费等多种支付方式的优劣以及对行业影响,同时对未来医保支付方式改革提出看法。With the continuous improvement of the universal medical insurance system,the traditional payment methods of medical insurance,such a global budget and fee for service,have been difficult to meet the development of modern medical and health care,as well as the management of medical insurance funds.Since the new round of medical reform,the reform of medical insurance of payment forms has been actively explored all over the country,which have achieved positive results in protecting the rights and interests of insured participants and in controlling unreasonable expenditures of medical insurance funds.However,health insurance management has not played an effectively role in guiding and constraining both sides of medical services,especially the providers.In this paper,we have compared the advantages and disadvantages of various forms of payment by literature analysis according to the reality of China,including fee for service,service unit,capitation,global budget,diagnosis related groups and dig data diagnosis-intervention packet,as well as their impact on the industry.Furthermore,we have proposed our own opinions in view of the reform of future health insurance payment.

关 键 词：医保基金 支付方式改革 医保管理 

分 类 号：R197[医药卫生—卫生事业管理]