| 引用本文：梅思思,郝倩,高洁鸿,等.基于交易成本的县域医共体医保基金结余形成路径研究[J].中国卫生政策研究,2025,18(5):13-19 |
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| 基于交易成本的县域医共体医保基金结余形成路径研究 |
| 投稿时间：2025-04-15 修订日期：2025-05-10 PDF全文浏览 HTML全文浏览 |
| 梅思思1，郝倩2，高洁鸿3，朱振国4，顾亚明1 |
| 1.杭州医学院公共卫生学院 浙江杭州 311399;2.杭州医学院卫生健康政策研究院 浙江杭州 310013;3.德清县卫生健康局 浙江湖州 313200;4.德清县疾病预防控制中心 浙江湖州 313200 |
| 摘要:医保基金“总额付费、结余留用、合理超支分担”是推动县域医共体高质量发展的核心制度，从实操角度重点是解决医保基金结余形成的来源渠道和医保基金留用的全过程管理等两个问题。本文基于交易成本理论，从医共体内部组织特征和外部医保支付设计等视角构建了县域医共体医保基金结余形成的分析框架，并结合浙江省德清县的典型研究，提出了厘清医保结余来源渠道、科学预算区域医保总额、医共体总额打包支付、统分结合多元付费、结算考核激励奖惩等五个方面的建议，探索医共体医保基金结余形成路径，以期为医保支付赋能县域医共体高质量发展提供理论依据与实践参考。 |
| 关键词:县域医共体 医保支付 结余 形成路径 交易成本 |
| 基金项目:浙江省软科学研究计划项目（2025C35003）；湖州市卫生健康委“公立医院改革与高质量发展示范项目” |
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| Formative pathways of medical insurance fund surplus in county medical communities： A transaction cost theory perspective |
| MEI Si-si1, HAO Qian2, GAO Jie-hong3, ZHU Zhen-guo4, GU Ya-ming1 |
| 1.School of Public Health， Hangzhou Medical College， Hangzhou Zhejiang 311399， China;2.Institute of Health Policy， Hangzhou Medical College， Hangzhou Zhejiang 310013， China;3.Deqing County Health Bureau， Huzhou Zhejiang 313200， China;4.Deqing County Center for Disease Control and Prevention， Huzhou Zhejiang 313200， China |
| Abstract:The “capitation payment with retained surplus and shared accountability for reasonable overruns” mechanism constitutes a pivotal institutional framework for advancing the high-quality development of County Medical Communities（CMCs）. This study addresses two critical operational challenges： identifying the sources of medical insurance fund surplus and optimizing the governance of fund retention processes.Grounded in transaction cost theory， we develop an analytical framework examining the formation of medical insurance fund surplus through the dual lenses of intra-organizational dynamics within CMCs and external medical insurance payment mechanism design.Utilizing Deqing County， Zhejiang Province as an empirical case， this research proposes a five-pronged strategy： Clarifying generation channels of insurance fund surplus， scientifically determining regional medical insurance budgets， implementing bundled payment mechanisms for CMCs， adopting hybrid payment models integrating unified and differentiated approaches， and establishing performance-based incentive systems. These findings elucidate the formative pathways of medical insurance fund surplus while offering theoretical and practical insights for enhancing payment system reforms to support CMC development. |
| Key words:County medical communities Medical insurance payment Surplus Formative pathways Transaction cost |
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