基于健康整合理念的城乡基本医疗保险按人头支付模式设计及系统评价研究

项目名称： 基于健康整合理念的城乡基本医疗保险按人头支付模式设计及系统评价研究

项目编号： No.71503170

项目类型： 青年科学基金项目

立项/批准年度： 2016

项目学科： 管理科学

项目作者： 荆丽梅

作者单位： 上海中医药大学

项目金额： 17万元

中文摘要： 按项目付费为主的支付方式和“医”“保”分割的现状导致医疗费用上涨迅速、医疗资源浪费严重、群众就医负担增加、医保基金赤字问题严峻，合理选择医保支付制度并与医疗服务体系有效整合成为各方关注的焦点。本研究以健康整合理念为指导，以按人头支付为引擎，整合家庭医生制度、分级诊疗制度，构建政策方案研制-可行性论证-政策干预及执行跟踪-系统评价-反馈完善方案的政策研究回路，研制基于家庭医生制的按人头支付改革政策方案，在可行性论证的基础上选择典型地区开展政策干预并严密观测政策执行中的偏差，进而利用干预对照研究设计和倍差法分析对干预的效果进行系统评价，最后在问题分析的基础上反馈完善政策方案。预期可通过按人头支付的撬动，建立家庭医生健康和费用“双重守门人”机制，构建分级诊疗的有序有效医疗服务体系，实现“医”“保”联动协同、释放改革红利。可为政府决策和试点推广提供理论和实证依据，具有很好的开拓性和推广应用前景。

中文关键词： 卫生政策；基本医疗保障制度；卫生改革；卫生体系；新型卫生合作医疗

英文摘要： The fee-for-service as the current main payment method and the split of medical service system and insurance payment system in China brings about the rapid growth of medical costs, serious waste of medical resource, increasing disease burden of residents, and the medical insurance fund deficit. Thus the urgent problem need to be solved is to choose a rational payment for insurance system to integrate the medical service system. According to the integrated care theory, our research aims to design a capitation reform mode of urban and rural basic medical insurance, effectively integrated by the family doctor system and healthcare alliance dual referral; to conduct a policy intervention in sampled typical area based on a feasibility demonstration and strictly observe the deviation during implementation; to systematically evaluate the effects between the intervention area and control area by Difference-in-Differences method; to refine the policy scheme based on problem analysis and feedback. This followed a policy-developing circuit including scheme development, feasibility demonstration, intervention and execution tracing, system evaluation and feedback. Through levered by the capitation reform, we anticipate to build dual gatekeeper for both health and costs mechanism, to standard the first contact in community and reasonable sequential referral order, to achieve integrated development of health insurance payment system and medical service system, and to release the reform bonus. The research achievement would offer theoretical and practical evidences to policy makers on the on the application of capitation reform, and have a good application prospect.

英文关键词： health policy;basic medical insurance system;health reform;health system;new health cooperative medical scheme