医保支付中如何合理控制费用

医保支付中如何合理控制费用

摘要

医疗费用的迅速增长已成为全球性问题，医疗保险第三方支付因其对医疗服务的经济杠杆作用而被看做是分担公众疾病负担、调控医疗费用增长的重要措施。

但医保支付并不能独立发挥作用、实现政策目标，从其核心内容来看，医保对医疗服务供方的支付涉及到支付标准、支付范围、质量要求的确定，支付方式作为调节利益的杠杆，必须找到调节利益的支点与传导机制，必须有配套制度的支持，并受环境影响。医保支付合理控制医疗费用的过程是一个系统过程。

本研究对国内外医保支付改革的进展进行了归纳整理，对各国的医保支付方式及其核心内容包括支付标准、支付范围、服务质量，医保支付的支持条件以及环境进行综合分析，结合支付方式的特征及政策目标等理论内容，明确了医保支付合理控费是一个受多因素影响的过程。

本研究从北京市某公立三甲医院HIS系统提取该院2010‐2014年不同付费方式住院

费用相关数据，用 Excel2010、Acess2010 进行整理分析，探索医保支付政策的变化对定

点医院的影响，并尝试从发现的问题中提炼医保支付合理控费作用的影响因素。

依据系统科学理论与方法，本研究构建了医保支付合理控制医疗费用的系统模型。系统要素包括核心要素与支持要素。核心要素包括医保支付标准、支付范围、服务质量，支持要素包括价格、谈判、激励、监督、医院管理理念。系统环境包括医疗保障制度、医疗服务体系、市场机制与政府行为、信息系统。医保支付合理控费作用的发挥在于系统核心要素的合理运用以及支持要素的配套，而核心要素与支持要素的作用都以系统环境的演化为基础。

在以上研究的基础上，本研究提出促进医保支付合理控费的关键策略：

（1）推进医药卫生体制改革，提供支付方式合理控费的适配条件。

（2）构建利益相关方谈判平台，促进医保支付核心内容适时调整。

（3）树立医院与支付方式改革有效衔接的管理理念，提高医院控费主动性。

（4）建立与支付方式相容的医生激励制度，发挥支付方式引导下医生控费主体作用。

关键词医保支付方式住院费用费用控制系统模型

Study On Controlling Medical expenses Rationally ByMedicare payment.

ABSTRACT.

The rapid growth of medical costs has become a global issue currently,

third‐partypayment of medical insurance is seen as an important measure of sharing publicdisease burden and regulating growth of medical costs for its economic leverage tomedical services. But third‐party payme nt does not pay function independently toachieve policy objectives because its core content is about payment method, paymentrates and payment scope. The mechanism of interest transmission and supportinstitution are significant, and environment plays a key role. Controlling medicalexpenses reasonably is a systematic process.

The research has summerized the progress of reform of medicare payment athome and abroad , and the core of national health insurance payment includingpayment method, payment range, payment standard, supporting condition ofmedicare payment and environmental conditions. Combined with characteristics andobjective of medicare payment, that controlling medical costs reasonably is affected bymultiple factors is determined.

The research has extracted information of hospitalization expenses of differentpayments from HIS system of certain grade‐three general hospital in Beijing, andanalyzed the data by Excel and Access software, to discover the impact of medicarepayment policy and to try to refine factors of controlling medical expenses reasonablyby medicare payment.

Based on system science, the system model of controlling medical expensesresonably by payment has to be constructed. The core elements, support elements andsystem environment are included in the system. It refers to the core content of the coreelements that including payment method, payment range, payment standards. Price,negotiation, motivation, supervision and hospital management philosophy are includedin support elements. Medical insurance system, medical service system, marketmechanisms and government action ,and information system are included in systemenvironment. The interaction of system elements, and the impact of systemenvironment play a significant role in controlling medical expenses reasonably bymedicare payment.

Based on above research, the study presents key strategies of controlling medicalexpenses reasonably by medicare payment:

（1）Promote medical and health system to provide adaptive conditions.

（2）Build stakeholder negotiation platform to facilitate timely adjustment of thecore content of medicare payment.