肺结核患者全疗程按人头打包付费模式与付费标准构建研究简介  

Intrudoction of study on the capitation compensation mechanism among pulmonary tuberculosis patients with a full period of treatment and payment standard

作　　者：张婧怡 代珊珊 张礼亮 田佳帅 蔡心雨 高广颖 Zhang Jingyi;Dai Shanshan;Zhang Liliang;Tian Jiashuai;Cai Xinyu;Gao Guangying(School of Public Health,Capital Medical University,Beijing 100069,China)

机构地区：[1]首都医科大学公共卫生学院,北京100069

出　　处：《中国防痨杂志》2024年第5期502-508,共7页Chinese Journal of Antituberculosis

基　　金：国家自然科学基金(71874113)。

摘　　要：结核病的流行会带来负外部效应,而医疗保险(简称“医保”)支付方式可以促进医院主动控制费用,减轻患者负担。由此,作者结合结核病防治特点,基于国内外经验,构建符合肺结核防治特征的全疗程按人头打包付费模式,按疾病类型进行全疗程打包,依据临床路径及历史数据测算服务包、支付标准和年度预付基金总额,以此调动各级定点医院的积极性。通过对宜昌市进行支付标准测算结果显示,该模式适合于肺结核疾病本身,有利于控制不合理医保支出,提高基金效能,通过发挥医保支付的杠杆作用调节医院诊疗行为,进而形成以人为本的全疗程、全周期的健康管理模式,为其他地区和国家的肺结核支付方式改革提供参考和依据。The spread of tuberculosis will bring negative externalities,while medical insurance payment methods can promote hospitals to actively control costs and reduce the burden on patients.Based on domestic and international experience,the author established a full-course capitation compensation bundled payment model that was in line with the characteristics of tuberculosis prevention and control.The full course of treatment was packaged according to disease type,the service package,its payment standard,and the total annual prepaid fund were calculated by the clinical pathways and historical data,to mobilize the enthusiasm of designated hospitals at all levels.The calculation results of the payment standard in Yichang City showed that this model was suitable for tuberculosis,which was conducive to controlling unreasonable medical insurance expenditures,improving fund efficiency,and regulating hospital diagnosis and treatment behavior by leveraging the leverage of medical insurance payments,thereby forming a people-oriented full-course and full-cycle health management model.Above all,this study will provide a valuable reference and reliable basis for the reform of tuberculosis payment methods in other regions and countries.

关 键 词：结核 肺 支付标准制定和审核 预付费卫生计划 

分 类 号：R197.1[医药卫生—卫生事业管理] R521[医药卫生—公共卫生与预防医学]