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

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.

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。

城乡基本医疗保险制度在新医改以来在“广覆盖、保基本”方面取得显著进展，但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。本研究综合应用多学科的理论与方法，设计基于家庭生签约首诊、联合体双向转诊的按人头支付改革政策方案，选取典型地区进行政策干预，进而系统评价改革的效果，分析问题及其影响因素，并提出对策建议反馈性地用于基本医疗保险按人头支付改革方案的完善，为按人头支付改革的理论和实证研究提供借鉴。.理论设计部分，以健康整合理念为指导，综合运用定性和定量研究方法，基于梳理国内外现状的基础上，以按人头支付为引擎，整合家庭医生制度、分级诊疗制度，研究设计按人头支付改革政策方案。.实证研究部分，结合地域特点和基本医疗保险的实际情况，选取上海市浦东新区作为典型案例，并在政府各级部门的支持下实施新型农村合作医疗按人头支付改革的政策干预实践。同时，为系统评价实证干预的效果，研究设计了结果-过程-结果三级指标体系，通过横向和纵向的比较研究发现，按人头支付干预后，医疗保险基金运行风险得到很好的控制，基金扭亏为盈；参保对象的医疗服务需求未受到抑制，门诊和住院服务利用均合理释放；通过时间序列预测模型分析发现，患者的次均医疗费用的增长受到明显遏制，患者医疗费用负担有所减轻；供需双方的满意度均未受到明显影响，新型农村合作医疗参保对象的满意度明显高于城镇居民基本医疗保险和城镇职工基本医疗保险。