美国Medicare支付方式改革历程和驱动因素及对我国的启示
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篇名: 美国Medicare支付方式改革历程和驱动因素及对我国的启示
TITLE: Reform Course and Driving Factors of American Medicare Payment Mode and Implication for China
摘要: 目的:为深化我国医保支付方式改革提供参考。方法:通过分析美国老人保险(Medicare)支付方式的具体改革历程及改革的驱动因素,结合我国目前支付方式改革的背景,提出推进我国医保支付方式改革的建议。结果与结论:美国Medicare支付方式历经后付制、预付制、按价值支付3个阶段,分别采用按服务项目付费、按疾病诊断相关分组付费(DRGs)、按服务价值付费的支付方式。其变革是美国技术、政治、社会文化3个系统综合作用的结果,合理诊疗与控费的需求推动后付制向预付制转变,而服务质量危机、服务成本上升及医患矛盾驱使着支付方式向按价值支付转变。支付方式改革对美国Medicare产生了一定积极影响,降低了医疗费用支出,提升了服务质量。建议我国可借鉴美国Medicare支付方式改革经验,在目前DRGs试点的基础上,推进全国范围内预付制改革,同时为避免美国后期出现的服务质量危机,需引入按价值支付理念,建立激励约束机制并加强全流程的监管配套制度建设,以保障医保支付方式改革的顺利进行。
ABSTRACT: OBJECTIVE:To provide reference for deepening the reform of medical insurance payment mode in China. METHODS:By analyzing the specific reform process and driving factors of American Medicare ,and considering the background of current payment reform in China ,then some suggestions were put forward to promote the reform of medical insurance payment mode in China. RESULTS & CONCLUSIONS :The payment mode of Medicare in the United States had undergone three stages , which were post-payment system ,pre-payment system and value-based payment system. The payment modes included payment by service items ,payment by disease diagnosis related groups (DRGs)and payment by service value. The change was the result of the comprehensive effect of the three systems of technology ,politics and social culture in the United States. The demand for reasonable treatment and control fees drove the change from post-payment system to pre-payment system ,while the crisis of service quality , the rise of service cost and the contradiction between doctors and patients drove the change to value-based payment. Payment mode reform had a positive impact on Medicare in the United States ,reducing medical expenditure and improving the quality of service. It is suggested that China should draw lessons from the experience of the United States in reforming the prepayment system nationwide on the basis of the current DRGs pilot projects. Meanwhile ,in order to avoid the medical quality crisis in the later period of the United States ,it is necessary to introduce the concept of value-based payment ,establish incentive and restraint mechanisms and strengthen the construction of the regulatory supporting system for the whole process.
期刊: 2020年第31卷第05期
作者: 朱梓荣,张伶俐,颜建周,邵蓉
AUTHORS: ZHU Zirong ,ZHANG Lingli,YAN Jianzhou ,SHAO Rong
关键字: 美国老人保险;医保支付方式改革;按疾病诊断相关分组;驱动因素
KEYWORDS: American Medicare ;Medicare payment mode reform ;Payment by disease diagnosis related groups ;Driving factors
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