安徽省新农合大病保障政策的经验与挑战

安徽省在大病保障政策设计中,实行按病种付费、定点救治、分级医疗与提高医疗保障水平四方面紧密结合。随着大病保障政策不断完善及大病病种数量逐年增加,参合农民获得了更多补偿,新农合基金效能得以提升,医疗机构也得到了发展。但是,随着政策的推进,还存在分解收费、临床路径执行不到位、基层医疗机构的服务能力亟需提高等问题。最后,提出了进一步完善这项制度的政策建议。     

某医院新农合按病种付费实施情况探析

2011年,北京市率先在全国启动按病种付费试点改革,随后该支付方式被推向全国。实施按病种付费确实有利于减轻新农合患者的医疗经济负担,但具体的政策执行却需要医疗机构的积极配合和落实。通过对某三甲医院新农合按病种付费方式实施情况的研究,了解医疗机构在实际执行按病种付费制度中取得的成效及存在问题,为合理改善医院新农合按病种付费管理工作提供依据。     

论新型农村合作医疗制度中按病种付费制度的发展策略

我国城市医疗机构由于技术力量有限、管理机制不完善等原因,一直没有将按病种付费真正引入和实施。相比之下,新型农村合作医疗制度下的农村医疗机构能够为粗犷式的按病种付费提供适合的发展条件,而实施按病种付费对新型农村合作医疗基金具有控制不合理费用、保障基金安全性的作用。所以,按病种付费在我国的发展策略可以尝试先从农村医疗机构的粗犷模式开始,然后,完成由简到繁、从农村到城市的推广。     

医疗服务提供方对按病种定额付费政策的认知现状——以四川省成都市为例

目的：了解医疗服务提供方对按病种定额付费政策的认知现状,为进一步完善相关政策提供依据。方法：采用半结构式访谈方法,对9家医院38名工作人员和患者进行深入访谈。结果：各级医院积极执行按病种定额付费政策,并制定了相应的费用控制和管理措施,但各医院按病种定额结算的病例比例较低,在执行过程中存在着对病例纳入依据认识不一致、医疗服务提供方认为费用标准制定较为笼统等问题。结论：成都市按病种定额付费取得了一定成效,但也存在一些问题,需根据病种费用信息测算标准费用,完善按病种定额付费结算方式;进一步明确按病种定额付费病例的纳入依据和原则;逐步增加按病种定额付费疾病的种类;加强对医疗服务提供方的监管力度;引导医疗服务提供方建立有效的激励机制。     

台湾地区全民健保实施按病种付费的经验及启示简

对台湾地区从1995年3月1日实施全民健康保险以来按病种付费的演变过程做了介绍,描述了“论病例计酬”和“台湾版诊断相关分组”的具体实施方法及其对医疗费用与质量的影响,并从制度层面和医疗机构层面提出推广按病种付费的建议。     

台湾地区全民健保实施按病种付费的经验及启示

对台湾地区从1995年3月1日实施全民健康保险以来按病种付费的演变过程做了介绍,描述了"论病例计酬"和"台湾版诊断相关分组"的具体实施方法及其对医疗费用与质量的影响,并从制度层面和医疗机构层面提出推广按病种付费的建议。     

按病种结算超定额费用原因分析及对策探讨

目的：探讨按病种付费对医疗机构提高控费意识,规范医疗行为,减少不合理医药费用,降低患者的医疗经济负担和按病种付费的执行初期暴露的问题。方法：对该院2015年按病种付费超支情况进行了原因分析,并通过政策宣讲、规范收费、规范治疗方案等方法控制过度医疗行为。结果：经过以上措施的落实,2016全年参与按病种付费的病案总体结算未超支。结论：科学合理的医保管理有利于在保证医疗安全的同时做到医疗费用的控制。     

广西合浦县按病种付费试点效果分析

目的：通过分析按病种付费方式在新型农村合作医疗中运行的效果,探讨其实行的可行性和条件.方法：选取广西合浦县实行按病种付费和按项目付费下合作医疗开展情况做对照分析.结果：病种选择较为合理,医疗机构住院费用总体有所下降,部分病种费用降低.讨论：按病种付费对控制医疗费用增长有一定效果,但在执行过程当中,应该让医院也承担费用风险,同时合管办既应加强对医疗服务的审查,又应制定出合理的补偿标准.     

住院分娩医保按人头付费降低剖宫产率的探讨

目的了解住院分娩产妇按人头付费对降低剖宫产率的影响。方法通过分析国内剖宫产率居高不下的主要影响因素,对比国内外医保支付方式,对按人头付费医保方式进行探讨。结果按人头付费医保方式可有效降低剖宫产率和住院费用,促进医疗质量,降低新生儿死亡率。结论通过住院分娩医保按人头付费,降低非医学因素的剖宫产。医师始终遵循临床路径管理指南,避免了重复检查、可避免的药品使用和耗材的消耗,因而实现了优质服务和适度医疗的统一,不仅保证了参保人员享受基本医疗服务的权益,也保障了医疗质量和医院的合理利益,同时,使医疗机构逐步将工作的重点转向预防保健工作,通过加强孕期教育,降低剖宫产率,降低成本,增加业务收支结余,配合医疗体制改革,具有重要的社会效益和经济效益高。为了降低剖宫产率,必须改变现有的医保按病种付费的支付模式。     

按病种支付释放出哪些信号

正在提质和控费间找平衡《医疗保险按病种付费病种推荐目录》的公布,体现出医保支付方式改革正在提速,同时也释放出几个信号:医保按病种支付是大趋势,这源于按病种支付的几大好处:促使医疗机构和医务人员在提供医疗服务时必须遵循合理的临床路径,从而遏制各种形式的过度医疗、乱收费;利于实现疾病全程管理,提高效率与质量,包括减少平均住院日、提高医疗资源使用效率、维护医疗服务连续性;取得医患和医保共     

Epidemiological surveillance of Chagas disease

Chagas disease still constitutes an important medical problem in affected countries. In some, the extent of the disease is still unknown and control programs have not been implemented. In others the disease has been reduced due to regular control programs and other economic and social factors. Epidemiological surveillance with community participation to guard against disease transmission is now the basic challenge. Applied research and in-depth reformulation of health systems are required to establish efficient and sustainable Chagas disease surveillance programs, considering low density of peridomiciliary vectors as the most relevant factor. In addition, a large population of already infected, poor individuals require specific medical attention and social security. As a consequence of health care decentralization, Federal institutions such as the Brazilian National Health Foundation (FNS) are being progressively decommissioned, and new participants must be engaged in the process. Communities themselves, together with regional and local institutions, must take charge of surveillance in order to guarantee its efficiency and sustainability.     

试论制度安排与健康公平的实现

健康公平是人类共同追求的目标,但由于经济、社会和文化等因素又造成了健康的极大不公平。遗憾的是,我国卫生改革从一开始就缺乏伦理基准,医疗服务过度市场化倾向、政府责任不到位和伦理缺席已将卫生改革引向功利主义的死胡同,使得卫生改革背离了公正目标。如何通过有效的公共政策和制度安排促进健康公平,这是全社会关心的问题。在今后的深化改革中,必须加大政府的投入,围绕公平目标,建立覆盖全民的医疗保障体制。     

中国社会办非营利医疗机构:动力、挑战与对策

开展社会办非营利医疗机构是坚持公共医疗卫生的公益性质、实现人人享有基本医疗卫生服务的重要途径。在一系列政策支持下,目前中国社会办非营利医疗机构取得了一系列成效。但由于公立医院的绝对主导地位,社会办非营利医疗机构在准入门槛、发展空间以及政策执行等方面仍然存在诸多限制。必须充分认清鼓励社会办非营利性医疗机构的意义,通过落实政策优惠、完善监督机制、探索多点执业、优化资源配置等方式,保障社会办非营利医疗机构的发展能力、人才建设和发展空间,推动社会办非营利医疗机构的健康发展。     

北京某院DRGs收付费模拟运行效果评价

目的以TR医院为例,评估北京市DRGs收付费政策模拟运行两个月的效果。方法通过一个准实验方案,以模拟运行为控制因素,收集2017年12月-2018年1月(模拟运行前)和2018年12月-2019年1月(模拟运行后)时间段的相关医疗指标,从病组变化、服务能力、服务效率和医疗质量四个层面结合相关统计学方法进行前后侧对比。结果重点学科覆盖病组数改革后增加了7个(P<0.05),但全院总体病组数无变化;服务量和诊疗难度有所提升;平均住院日等多个效率指标较改革前均有显著改善(P<0.05);医疗质量指标较改革前无统计学差异(P>0.05)。结论目前,DRGs收付费在该院的模拟运行效果主要体现在服务能力和效率上,刺激相关流程的改善,同时保证了医疗质量,但控费效果不显著。建议在充分论证的基础上,正式推行DRGs收付费改革,关注结算等待时间的影响、病理医师人力资源配备、政策间衔接等问题。远期来看,DRGs收付费改革可发挥多方面积极作用,有助于保障群众基本医疗权益和医保制度长期可持续发展。     

基于DRG的医疗服务质量与绩效评价干预模式研究

目的基于疾病诊断相关组(DRG)的上海市嘉定区某二级综合性医院的医疗服务质量与绩效评价干预模式进行分析,为建立公立医院绩效考核评价机制提供参考依据。方法本组以"DRG住院医疗服务监测与分析系统"等为研究平台,通过在线上报的病案首页信息,对某二级综合性医院2018—2019年基于DRG的住院患者入组病例数、CMI值、DRG组数和总权重等指标进行比较,同时对区域病种难度、区域手术难度以及MDC医疗服务能力、效率和安全进行比较,并从三个维度进行综合分析。结果2018年总病例数12464例,入组病例数12398例,入组率为99.47%;2019年总病例数12301例,入组病例数13037例,入组率为99.51%。其中DRG组数上升了7.94%,CMI值上升了9.64%,呈良好发展态势。产能、效率、安全和综合得分均呈上升趋势,其中安全得分上升了12.66%,综合得分上升了6.12%。MDC医疗服务能力、效率和安全和去年同期相比也呈上升趋势。结论基于DRG的医疗服务绩效评价具有科学性、客观性和可比性的特点,可以帮助医疗机构发现医疗行为存在的问题,有的放矢地进行干预,通过DRGs这个管理工具在费用控制、质量管理、安全控制、学科评估和绩效评价等方面发挥其综合作用。     

A framework for applying ethical theory to public health practice.

Like most other public health agencies, the Georgia Department of Human Resources, Division of Public Health (DPH) has encountered a growing number of questions and conflicts with ethical implications. To address these and other questions, DPH started to develop a framework, in January 1985, specifically related to solving problems, setting priorities, and developing policy that adds an ethical perspective. DPH must deal with issues and conflicts that transcend the traditional model of medical care: with the new economic reality, programs must continue with less resources; medical technology is now raising questions, but not necesarily answers, related to life and death; and the rights and responsibilities of individuals and institutions are not clearly defined. In this context, DPH has started to examine ethical considerations with respect to the individual and the community. An interface exists between ethical theory and health care. Over the years, however, this relationship has assumed different manifestations, ranging from the formation of precise conduct codes for health care professionals to the establishment of review boards that examine specific morally questionable procedures. DPH's purpose in applying ethical theory to its health care practices is not to develop an inflexible code nor a committee to review isolated cases of moral conflict. The purpose is to use ethical theory as a form of vision for the remainder of the 1980s and beyond.     

The institutionalization of public health training and the health sciences

The health of the population is determined by a number of ecological determinants in addition to medical care. Therefore a close relationship exists with the social and political context in a society. With regard to the health care system, schools of public health as institutions for training, research, and services have to focus on four main deficits in the area of information, prevention, social gradients, and the regulation of health care delivery. A task profile derives which comprises (a) training for research and services, (b) monitoring population health and setting of priorities, (c) applied research on public health, (d) consulting the decision makers, and (e) intervention and public accountability. How to perform in these areas has to be related to basic ethical principles, notably, equity, participation, subsidiarity, sustainability, and efficiency. Furthermore, international trends in modern education have to be considered as for the European Union in the Bologna Declaration of 1999, with reference to academization and internationalization of advanced studies. The resulting institutional profile of modern schools of public health is characterized by their academic basis, interdisciplinarity, and multi-professionality. The paradigm of the New Public Health is an equal merger of medical and social sciences, a predominantly postgraduate study program, an international scope, close links to the government, local networks with service institutions, and a focus on contemporary health issues. In the former socialist economies of Central and Eastern Europe a regional collaboration beyond borders (the concept of regionality) is apt to support the achievement of international standards of excellence for newly developing schools of public health.     

Dépistage organisé du cancer du sein en France : pour une optimisation de l’information

BackgroundBased on international and national recommendations, organized breast cancer screening in France raises questions of medical ethics built around the key concepts of individual autonomy and public health policy. Because of the evolving knowledge, professionals and institutions involved in the program must review the ethical values associated with this medical practice.MethodsThe ethical aspects of organized breast cancer screening were studied. In response to newly acquired knowledge highlighted by a review of texts governing this practice in France, proposals for changes resulting from reflections of a working group coordinated by the National Cancer Institute are presented.ResultsEthical issues raised by screening must find expression in the general principles of the program's organization: acceptability of screening, efficiency, adverse effects, equity of access, free care…, but also at different stages of the procedure: information delivery, first and second invitations, refusal of further diagnostic investigation…ConclusionA better match between breast cancer screening and recently developed knowledge requires optimal information delivery to women targeted by the program as well as a stronger role for the referring healthcare professional.     

连续—碎片—整合——我国农村三级医疗卫生网络服务提供模式的历史演变及启示

几十年来,经济社会的巨大变革所引起的政府卫生决策意识改变导致我国农村卫生服务网络提供连续性卫生服务呈现明显的波动性：计划经济时代,＂分级分工,就近就医＂的服务模式曾是我国连续性服务的理念萌芽和初始实践;改革开放以来则形成了＂自由择医,碎片化提供＂的非连续服务模式;2009年公共卫生服务均等化实施后则呈现＂基层就医,连续综合＂的整合服务模式的发展趋势。上述三个阶段服务提供模式的波动特征背后隐含着不同时期政府意识形态对卫生服务治理的深刻影响,充分证明了基本医疗保健服务具有明显的政治脆弱性。这种历史演化特征的政策动因为我国以及转型国家维持卫生服务网络延续连续性服务模式提供了诸多政策经验和启示：重视基本保健策略,建立完整的基层卫生体系框架和系统的、整合的运行机制以及重视以人为中心的服务提供理念等。     

湖北省A县农村儿童先心病医疗保障研究

目的分析农村儿童先天性心脏病医疗保障试点工作运行效果。方法运用SPSS17．0软件对湖北省A县先天性心脏病住院患儿就医费用及补偿数据进行分析。结果先天性心脏病患儿实际补偿比低于新农合全体患者,患者负担沉重;支付方式改革有效控制了费用增长,定额支付标准能够引导供方诊疗行为：支付方式改革可能出现了人为加重诊断的负面效应。结论逐步扩大重大疾病保障的病种覆盖范围,采用混合式的补偿模式,科学进行疾病分类,制定和调整单病种定额支付标准,针对支付方式改革可能产生的负面效应针对性地加强医疗机构监管。