全科医生按人头医保全口径预付管理方案的模式架构探讨

发布时间：2018-03-12 12:14

本文选题：全科医生　切入点：保险　出处：《中国全科医学》2015年29期 　论文类型：期刊论文

【摘要】：目的针对总额预付制度下,政府确定合理医保总额难度大的问题以及医疗机构存在少收医保患者、降低服务质量等现象,探索全科医生按人头医保全口径预付管理方案的模式架构。方法本研究采用理论研究与实证研究相结合的方法,通过借鉴国外成熟的医保费用控制经验和理论及充分吸收国内研究机构的相关研究成果,探索适合我国国情和医疗卫生发展需要的合理控制医保费用的方法和措施。结果拟建立起以主要在社区卫生服务中心就诊的签约居民为预付对象,以签约全科医生为责任人,以社区临床路径为管理工具,以疾病控制达标率、成本管理合理性和签约对象满意度为判断标准的按人头医保全口径预付管理方案,形成符合客观现实的模式架构。结论可尝试通过全科医生家庭签约服务制,按人头医保全口径预付管理,实现全科医生"守健康、守费用",使其真正成为社区居民健康的守门人。此模式尚不成熟,还需实践进一步证实。
[Abstract]:Objective to solve the problem that it is difficult for the government to determine the reasonable total amount of medical insurance under the system of total advance payment, and to reduce the quality of service and so on. To explore the pattern structure of general practitioners' full caliber prepaid management scheme based on head medical insurance. Methods this study adopts the method of combining theoretical research with empirical research. By drawing lessons from the mature experience and theory of medical insurance cost control abroad and fully absorbing the relevant research results of domestic research institutions, To explore the methods and measures of reasonable control of medical insurance cost suitable for the situation of our country and the needs of medical and health development. Results We proposed to set up prepaid residents who mainly visit the community health service center and take general practitioners as the responsible persons. Based on the management tools of community clinical pathway, the rate of disease control, the reasonableness of cost management and the satisfaction degree of contract object, the full caliber prepaid management scheme based on head medical insurance was used. Conclusion through the family contract service system of general practitioners, the general practitioners can be managed in advance according to the full caliber of medical insurance, so that the general practitioners can keep their health. Keep the cost ", make it become the gatekeeper of the community residents' health. This model is not mature yet, still need the practice to prove further."
【作者单位】：上海市浦东新区潍坊社区卫生服务中心;复旦大学附属中山医院全科医学科;
【基金】：上海市浦东新区卫生与计划生育委员会社区卫生项目(PW2014C-26) 上海市浦东新区卫生系统重点团队建设资助项目(PWZq2013-11)
【分类号】：R197.1

【参考文献】