| 引用本文：于淼, 杨燕绥, 张丹.管用高效医保支付二元结构研究：病组分值与健康绩效[J].中国卫生政策研究,2022,15(7):1-7 |
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| 管用高效医保支付二元结构研究：病组分值与健康绩效 |
| 投稿时间：2022-06-25 修订日期：2022-07-16 PDF全文浏览 HTML全文浏览 |
| 于淼1, 杨燕绥1, 张丹1,2 |
1. 清华大学医院管理研究院 北京 100084;
2. 清华大学深圳国际研究生院 广东深圳 518055 |
| 摘要:2020年，中共中央、国务院出台的《关于深化医疗保障制度改革的意见》引领我国医疗保障进入2.0发展时期，并提出建立“管用、高效”的医保支付机制。本文基于全球医保改革的视角，运用卫生经济、结构分析、案例分析等方法对医保支付机制进行研究，描述了病组分值点数付费和结余留用机制抑制过度医疗、紧密型医共体人头加权总额付费和健康绩效评估促进转型的作用机理。管用机制重在管理和控制，高效机制重在调动当事人积极性与绩效考核，由此形成医保支付二元结构及其整体方案，以及从以治疗为中心转向以健康为中心的实施路径。同时，本文进一步描述了总额预算管理、病组分值点数付费、人头加权预算、健康绩效评估几个关键词的核心内容。 |
| 关键词:总额预算管理|DRG/DIP|人头加权预算|健康绩效评估 |
| 基金项目:国家社会科学基金重大项目（17ZDA121）；国家自然科学基金项目（72004112） |
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| Research on the dual structure of effective and efficient medical insurance payment: DRG/DIP and health performance |
| YU Miao1, YANG Yan-sui1, ZHANG Dan1,2 |
1. Institute for Hospital Management of Tsinghua University, Beijing 100084, China;
2. Tsinghua Shenzhen Intemational Graduate School, Shenzhen Guangdong 518055, China |
| Abstract:2020, 《The State Council on Deepening the Reform of the Medical Security System》leads China's medical security into the 2.0 development period, putting forward the establishment of "effective and efficient" medical insurance payment mechanism.Based on the perspective of the global health insurance reform, we review the successful layout DRG/DIP payment reform action plan for three years, and apply health economics, policy elements, Clinical Practice,structural analysis, case analysis and other methods to support the research of operation mechanism, we describe the two mechanisms of controlling excessive medical treatment by diagnosis-Intervention packet and retention of surplus in patients group, global payment of intensive medical community and health maintenance by performance evaluation mechanism.Effective mechanism focuses on management and control, and efficient mechanism focuses on mobilizing the enthusiasm of the parties and performance appraisal system.This paper describes the dual structure of medical insurance payment and its overall scheme, especially the total payment mechanism of the compact medical community.And the implementation path of health insurance payment transformation from treatment-centered to health-centered.We further describe several key contents, including global budget management, diagnosis-Intervention packet, cap-weighted budget and health performance evaluation. |
| Key words:Global budget management|DRG/DIP|Cap-weighted budget|Health performance evaluation |
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