新医改下的杭州市基本医疗保险支付方式改革研究

发布时间：2018-04-05 07:28

本文选题：杭州市　切入点：基本医疗保险　出处：《浙江财经大学》2014年硕士论文

【摘要】：自从城镇基本医疗保险制度建立以来，各地都在积极探索行之有效的医保付费方式。2009年新旧医改转折之年后，医疗保险支付方式改革更是成为了深化我国医药体制一个热门的话题。城镇基本医疗保险支付方式在保障参保人的权益、规范医疗服务行为、控制医疗费用增长和促进医疗机构发展等方面都发挥了中流砥柱的作用。而在医疗卫生体制深化的过程当中，城镇基本医保支付方式改革注定被赋予了更多的责任和期望。开展基本医保支付方式改革的目的有三方面：一、重新构建医疗服务机构收费和补偿机制；二、促进卫生资源的合理配置，减少不合理的医疗资源浪费行为；三、控制医疗费用的过快增长。本文分为五个部分，文章第一部分以我国“看病难，看病贵”的现状为切入口，提出了卫生总费用过高和个人医疗负担过重的大背景，医疗支付方式改革作为深化医药体制改革的任务之一，对于降低卫生费用和减轻个人医疗负担起到至关重要的作用。研究用了文献法律法规分析法、个案分析法和统计分析法。文献法律法规分析法的运用主要在对相关法律法规的归纳基础上，，对杭州市医保支付方式改革作脉络整理。个案分析法是将杭州市城镇基本医保支付方式改革作为案例，加以统计分析法对杭州市医保支付方式改革进行量化评估。第二部分从医保支付方式理论支撑着手，通过对不同支付方式的利弊进行简要分析，用选择支付方式和医保费用支付之间的相关关系图来对比不同医保支付方式的控费效果、服务质量效果和管理效果。第三部分以浙江省杭州市城镇基本医疗保险支付方式改革作为案例。回顾了杭州市医保支付方式以新医改为时间拐点下的两个阶段的大致情况：杭州市新医改前主要是以单一的按项目付费为主的医保支付方式，新医改后主要是以总额预算为基础，按项目付费、按单病种付费、按人头付费这四种支付方式混合作为最主要的支付方式。在对杭州市医保支付方法改革有了定性的概述后，对杭州市历年医保基金的收支结余、人均医保支出、人均医保报销率、个人负担、对医院的收支效果评估以及单病种付费效果等方面对杭州市医保支付方式进行综合效果评估。结合相对全面的医保支付方式定性描述和定量分析，对评估结果进行评价，肯定了杭州市新医改下医保支付方式取得的积极成效，也提出了新医改下的城镇医保支付方式仍然存在着不足需要改进之处。第四部分在借鉴国外德国、英国、美国和国内城市上海、北京、东莞支付方式较为多元化的支付方式，并结合当前杭州市医保效果评估，提出针对杭州市医保支付方式不足之处具有借鉴意义的经验。最后笔者综合上述四大部分对杭州市城镇基本医疗保险改进提出了颇具意义的建议。主要针对性建议包括五大方面：继续推进总额预算为核心的混合支付方式道路上，需要加强医保基金预算管理与监管，完善基本药物零差率销售制度、不但要建立科学合理的混合支付方式，更要积极发挥外围配套措施的作用。在本文最后，笔者对文章进行了结论，并在展望中畅想了杭州市理想的医保支付方式改革路线图。杭州市医保支付改革在2010年伊始，如今进入第四个年头，以“总额预付”为主的混合支付方式初具雏形。但在关于杭州市医保支付改革的文献中，尚未有相关学者对其进行过研究，笔者在探究杭州市医保支付问题上属于少数，尽管由于关于财务信息的保密性，数据的采集阻力重重，但仍然通过不懈的努力查阅到了相关资料并得以分析研究的继续工作，希望对推动杭州市城镇基本医疗保险改革起到一些建设性意见的作用。
[Abstract]:Since the basic medical insurance system since the establishment of the country are actively exploring the effective way of Medicare payment.2009 years old and the new health care reform turning point of the year after the reform of the medical insurance payment is to become the deepening of China's medical system is a hot topic. The rights and interests of the urban basic medical insurance payment in the insured persons, standardize the medical service behavior, control medical expenses of medical institutions to promote growth and development plays a mainstay role. In the process of deepening medical and health system, urban basic medical insurance payment reform to be given more responsibility and expectations.
There are three ways to carry out the reform of basic medical insurance payment system: first, rebuild the medical service institutions' charging and compensation mechanism; two, promote the rational allocation of health resources, reduce irrational medical resources waste; three, control the excessive growth of medical expenses.
This paper is divided into five parts, the first part of this article to our country "difficult and expensive situation" as the entrance, the total health costs are too high and the burden of the personal medical background, medical payment reform as one of the deepening medical reform tasks, to reduce health costs and reduce the burden of personal health to study the important role of laws and regulations. The literature analysis, case analysis and statistical analysis. The analysis of the laws and regulations mainly used in induction on the basis of the relevant laws and regulations, in Hangzhou, the reform of the medical insurance payment sequence finishing. Case analysis is the Hangzhou urban basic medical insurance payment reform as an example, analyzed the method of payment reform in Hangzhou city health assessment. The second part from the theoretical support to the medical insurance payment, according to A brief analysis of the advantages and disadvantages of the same payment, choose to pay by way of payment and insurance between the diagram to compare different medical insurance payment cost control effect, the effect of service quality and management effect. In the third part, taking Hangzhou city of Zhejiang Province, the urban basic medical insurance payment reform. As a case review of Hangzhou City medical insurance payment in the new medical reform of the two stages of time under the inflection point of Hangzhou city before reform is mainly based on single fee based medical insurance payment, the new medical reform is mainly based on the total budget as basis, paid by the project, according to the single DRGs, capitation payment as the four mixed the main payment way. In the city of Hangzhou with the reform of Medicare payment method qualitative overview, in past years in Hangzhou city health insurance fund balance, per capita health expenditure, The per capita Medicare reimbursement rate, individual burden of Hangzhou Medicare payment balance and effect evaluation of hospital DRGs and other aspects of the effect of comprehensive evaluation. Combined with the relatively comprehensive medical insurance payment analysis of qualitative description and quantitative assessment of the results of the evaluation, positive results have been achieved in Hangzhou City, the new medical insurance payment next, put forward under the new medical reform of urban medical insurance payment still exist deficiencies need to be improved. The fourth part from abroad in Germany, Britain, the United States and the city of Shanghai, Beijing, Dongguan payment payment is more diversified, and combined with the assessment of the current health care effect of Hangzhou City, put forward Hangzhou City medical insurance payment deficiency of meaningful experience. Finally the author integrated the above four most of Hangzhou city basic medical insurance is proposed Meaningful proposals. The main suggestions include five aspects: Road mixed payment continue to promote the total budget as the core, the need to strengthen the medical insurance fund budget management and supervision, improve the basic drug zero sales slip system, not only to establish a scientific and reasonable mixed payment, but also to actively play the role of peripheral supporting measures. At the end of this paper, the author has carried on the conclusion of the article, and in the future the imagination of a Hangzhou City ideal Medicare payment reform roadmap.
Hangzhou City medical insurance payment reform at the beginning of 2010, is now in the fourth year, in the "total amount of prepaid based mixed payment to take shape. But in the city of Hangzhou Medicare payment reform in the literature, there is no relevant scholars have done research on it, the author paid on the research of Hangzhou health care problem belongs to the minority, although the about the confidentiality of financial information, collect data but still heavy resistance, through the unremitting efforts of access to relevant information and analysis of the research work, we hope to promote the Hangzhou city basic medical insurance reform to some constructive comments.

【学位授予单位】：浙江财经大学
【学位级别】：硕士
【学位授予年份】：2014
【分类号】：F842.684;R197.1

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