新农合按病种付费实现路径研究

发布时间：2019-07-03 17:50

【摘要】：当前,我国新农合发展面临着在较低筹资水平下,提高保险保障水平的挑战。国际经验显示,按病种支付以病种分组和定价为技术核心,能够在控制不合理医疗费用、提高服务效率和医疗服务质量等方面发挥积极作用。我国许多地区在新农合制度建立初期就积极探索开展按病种付费改革。由于改革中还存在许多理论的和实践的难题和障碍点,各地的改革目标、路径等存在显著差异,虽然一些研究对这些模式进行比较分析和评估,但鲜有研究针对性提出我国农村地区推广按病种付费适宜路径,推动按病种付费改革在我国农村地区的顺利实施。据此,本研究具有重要的理论和现实意义。 [目的]基于现阶段我国基本国情,探索新农合按病种付费实现路径,确保医疗保险基金的科学、合理和高效运用。 [方法]本研究采取宏观与微观相结合、定性与定量相结合、归纳与演绎相结合的方法开展研究。资料收集方法包括：①文献研究。通过中外文数据库、相关部门网站,收集国内外有关按病种付费相关文献、政策文件、试点改革情况。②现场调查。了解陕西省镇安县和重庆黔江区等地卫生服务体系、新农合发展概况,了解按病种付费制度制定和实施进展。③个人深度访谈和专题小组访谈。了解按病种付费支付方式在实施过程中的障碍、运行规律、利益分配和关键影响因素,针对按病种付费改革监测评价指标体系的维度、指标设置等问题进行讨论。资料分析方法包括：①个案研究。研究陕西省镇安县和重庆市黔江区新农合按病种付费制度结构模型；以广西壮族自治区为例,探索按病种付费实现路径。②系统研究法。运用委托—代理理论论证医疗保险管理和经办机构、医疗服务提供方、参合患者、政府等多个主体间行为关系。③焦点小组座谈。深入了解新农合按病种付费支付方式制定和实施过程存在的障碍点和需解决的关键问题、可能的解决办法。④统计学方法。利用Excel、SPSS等统计软件计算按病种付费病种的病例数、均次住院费用、新农合实际补偿比等重要统计变量,通过统计指标比较分析,为效果评价和制度设计提供基础数据。 [结果]新农合按病种付费制度关键策略：①病种全覆盖策略——通过按病种定额付费、按病种限额付费和例外病例三种方式和途径实现病种全覆盖的策略。②医疗机构全覆盖策略——通过分别测算不同医疗机构支付价格和支付比例实现医疗机构全覆盖的策略,并提高医疗服务市场竞争性。③通过科学的方法,充分考虑物价增长、医疗技术更新、新型农村合作医疗方案的调整等多方面因素,在与医院协商和讨论基础上,制定合理可操作的病种定额标准的策略。④通过按病种定额付费、按病种限额付费、总额预算等不同形式,实现医保与医疗机构之间费用风险分担的策略。⑤基于制度的不完备性和局限性,建立客观完善的按病种付费制度运行监测评价体系,包括监测重心、监测内容、评价与反馈。⑥构建按病种付费可持续发展的策略,按病种付费制度包含的病种分组和病种支付标准要与可使用的资源和技术支撑相互协调;按病种付费制度要保证新农合基金安全,与新农合门诊统筹政策和重大疾病补偿等政策相衔接；按病种付费制度要与医院管理水平、自治程度相适应,满足组织层面的可行。 [结论]按病种付费制度结构模型包括制度设计、制度实施、所需外部环境条件。制度设计的核心是病种分组和病种定价；制度实施主要是规范管理和加强监管。按病种付费制度流程：①根据目前医改要求,统筹考虑各项制度、政策的衔接,合理切割新农合基金(门诊统筹、一般诊疗费、基本药物制度、大病救助等)。②确定按病种付费的病种、费用水平及其结算办法,据此与医疗机构谈判。③明确先决条件,确定实施方案,建立管理制度。④具体实施并同步开展运行和效果监测,发现问题并不断完善制度。按病种付费制度实施所需外部条件：①政府的决策意愿是是按病种付费实施的首要条件。②提高医院医疗服务能力和水平,包括通过县域范围卫生服务体系改革,增强医院尤其是乡镇卫生院能力建设,落实医院院长负责制,完善医院内部成本核算的财务管理制度是按病种付费制度顺利实施的重要环境构成。③充分发挥医疗保险机构的主动性,探索建立医疗机构与医保机构之间的谈判机制,加强对按病种定额付费的监管,建立奖惩制度,提高医疗保险机构管理水平,是按病种付费制度实施所需外部条件的组成部分。后续研究方向：①完善卫生信息系统；②实施临床路径；③改变卫生部门的角色和关系,提高服务提供者自治权。 [创新]一是理论层面,构建了新农合按病种付费制度结构模型,为各地制定并完善当地新农合按病种付费制度提供指导和借鉴。二是制度设计层面,基于新农合实践背景,提炼出按病种付费制度关键策略,遵循疾病的临床规律和疾病所具备的经济学费用分布特征,克服现实中存在的技术和管理障碍,通过划分定额病种、限额病种和例外病例,实现了按病种付费的病种全覆盖和医疗机构全覆盖。三是以引导医疗机构和医生合理的诊疗行为为目的,对新农合按病种付费管理制度和监测机制进行创新和完善,构建监测机制和监测指标体系。 [局限]一是理论研究的局限性。理论研究资料多来源于文献资料,受可查找文献资料的限制,缺乏中低收入国家背景,需要不断补充完善。二是实证部分的局限性。本研究没有对研究结论的实现路径进行可行性检验,外因导致广西地区没有实践按病种付费制度改革方案,实现路径目前只停留在理论或者政策制定层面,路径是否可行、效果如何等有待实践检验。三是研究时限的局限性。我国农村地区正在经历较为深刻的医疗卫生体制改革,这些改革措施直接或间接影响按病种付费制度的制定或者制度实施的环境。需要进一步研究。四是由于混杂因素影响,很难辨别按病种付费改革单一因素对医疗费用、医疗服务数量、医疗服务质量变化的影响。
[Abstract]:At present, the development of China's new agriculture is facing the challenge of raising the level of insurance guarantee at the lower raising level. The international experience shows that according to the disease seed payment, the disease seed grouping and pricing as the technical core, can play an active role in controlling the unreasonable medical expenses, improving the service efficiency and the medical service quality. In that early stage of the establishment of the new non-agricultural system, many regions of our country have actively explored the pay-for-pay reform. Because there are many theoretical and practical problems and obstacles in the reform, there are significant differences in the target, path, etc., although some studies compare and evaluate these models, However, there is little research to put forward the appropriate path for the popularization of the rural areas in our country to promote the smooth implementation of the payment reform according to the disease type in the rural areas of our country. Therefore, this study is of great theoretical and practical significance. [Objective] Based on the basic national conditions of our country at present, we should explore the path of the new agriculture to pay the cost of the disease, and ensure the scientific, reasonable and efficient transportation of the medical insurance fund. In this paper, the method of combining the macro and the micro, the qualitative and quantitative combination, the induction and the deduction is adopted in this study. The data collection method comprises the following steps: The study is to be made. The relevant documents, policy documents and pilot changes related to the cost of the disease are collected and collected at home and abroad through the Danish database and relevant department website. The situation of the leather. Now Field investigation. To understand the health service system and the development of the new agriculture in Zhenan County and Chongqing Qijiang District of Shaanxi Province, and to understand the development and practice of the payment system according to the disease type. Application progress. Individual depth interviews and small topics Group interview. To understand the barriers, operation rules, benefit distribution and key influencing factors in the implementation process according to the payment method of the disease, and to solve the problems such as the dimension of the evaluation index system and the index setting of the monitoring and evaluation index system according to the cost of the disease. Line discussion. Data analysis method includes:1 Case study. Study on the structure model of the new agriculture in Zhenan County of Shaanxi Province and the Qijiang District of Chongqing, according to the system structure of the payment system of the disease, and take the case of Guangxi Zhuang Autonomous Region as an example to explore the payment of the cost of the disease. current path Research. Use the entrusted agent theory to demonstrate the health insurance management and handling agency, the medical service provider, the participating patient, the government, etc. It's a relationship. It's a small focus. Group discussion. In-depth understanding of the obstacles and the key problems that need to be solved in the development and implementation of new and non-payment methods of payment of the disease, and possible solutions method of decision-making By using the statistical software such as Excel and SPSS, the important statistical variables such as the number of cases, the average hospitalization cost and the actual compensation ratio of the disease type are calculated by using the statistical software such as Excel and SPSS, and the results are compared and analyzed by the statistical index, so as to provide the basis for the effect evaluation and the system design. Clinical data.[Results] The key strategy of the new farmer to pay system according to the disease type: the whole coverage strategy of the disease type _ through the payment according to the type of the disease, three ways and means of paying and exception cases according to the limits of the disease type and the way to realize the disease type the coverage strategy. The full-coverage strategy of the medical institution _ implements the full-coverage strategy of the medical institution by measuring the payment price and the payment proportion of the different medical institutions, respectively, and improves the medical service On the basis of consultation and discussion with the hospital, it is necessary to develop a reasonable and operable disease quota based on the consultation and discussion with the hospital. The standard strategy is to realize the cost risk between medical insurance and medical institution by paying according to the rate of the disease, paying according to the limits of the disease, the total budget and so on. Based on the incompleteness and limitation of the system, the objective and perfect system of monitoring and evaluating the system of monitoring and evaluating the system of the payment of the disease is established, including the monitoring of the center of gravity and the content of the monitoring. Evaluation and feedback. In order to construct the strategy to pay the sustainable development according to the disease type, the disease type and the disease-type payment standard included in the system for payment of the disease are to be coordinated with the available resources and technical support; according to the system of payment of the disease, the new farm should be guaranteed The safety of the fund is connected with the policies such as the integration of the new agriculture and the outpatient service and the compensation of the major diseases; the payment system according to the disease type shall be in accordance with the management level of the hospital and the degree of self-government, and the organization shall meet the requirements of the organization [Conclusion] According to the system structure model of the system, the system design and the implementation of the system The core of the system design is the classification of the disease and the pricing of the disease; the implementation of the system is mainly the specification Management and strengthening of supervision. According to the process of payment system of the disease, according to the requirements of the current medical reform, the system shall take into account the connection of various systems and policies, and reasonably cut the new non-agricultural fund (outpatient plan, general clinic fee and basic drug system). And the cost level and the settlement method according to the disease type, the cost level and the settlement method. negotiation with a medical facility. A clear prerequisite for determining an implementation Establish the management system. Implement and synchronize the operation and effect monitoring, and find out the problems. And constantly improve the system. According to the external conditions required for the implementation of the payment system of the disease, the decision-making will of the government is to pay for the disease. The primary condition of the implementation is to improve the medical service ability and level of the hospital, including through the reform of the county-level health service system, and to strengthen the capacity-building and implementation of the hospital, in particular the township health center The system of the financial management of the hospital's internal cost accounting is to be implemented smoothly according to the system of the payment of the disease. To make full use of the initiative of the health insurance institution, to explore the mechanism of the negotiation between the medical institution and the medical insurance institution, to strengthen the supervision over the payment of the fixed rate of the disease, to establish a reward and punishment system and to improve the medical insurance The management level of the risk management institution is the external requirement for the implementation of the payment system of the disease Part of the condition. Follow-up study direction: improve the health information system; implement the clinical path; change the role and relationship of the health sector, and improve the suit The autonomy of the service provider.[Innovation] The first is the theoretical level, and the construction model of the new agriculture and the payment system of the disease is constructed, and the local new non-agricultural products shall be prepared and perfected according to the disease type. The second is to provide guidance and reference for the system. The second is the system design level. Based on the background of the new farming practice, the key strategy of the payment system according to the disease type is proposed, and the characteristics of the economic cost distribution provided by the clinical law and the disease of the disease are followed, and the technical and administrative obstacles existing in the reality are overcome. Through the division of the fixed disease species, the limit disease and the exceptional cases, the whole coverage of the disease with the cost of the disease is realized. The whole cover of the cover and the medical institution. The third is to guide the medical institutions and the doctors to make reasonable diagnosis and treatment, and to innovate and improve the management system and the monitoring mechanism of the new farmers according to the system and the monitoring mechanism of the disease, so as to build the monitoring system. Mechanism and monitoring index system.[Limitations The first is the limitation of the theoretical research. The theoretical research data is mainly from the literature, the limitation of the available documents, the lack of low-and middle-income countries In the background, it is necessary to constantly supplement and improve The second is the limitation of the empirical part. The present study has not carried out the feasibility test on the implementation path of the research conclusion, and the external result has led to the lack of practice in the Guangxi area to pay the system reform program of the disease, the realization of the path is only at the level of the theory or policy development, the path is feasible, How the effect is waiting to be tested 3. The limitation of the time limit of the study. The rural areas of our country are undergoing a more profound reform of the medical and health system, which directly or indirectly affect the payment system of the disease. To formulate or implement a system and fourth, because of the influence of the confounding factors, it is difficult to distinguish the medical expenses and the number of medical services according to the single factor of the cost of the disease,
【学位授予单位】：华中科技大学
【学位级别】：博士
【学位授予年份】：2014
【分类号】：R197.1;F323.89;F842.684

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