[1]方子衿,唐文熙,彭 倩,等.整合型健康服务组织医保支付模式的设计 ——基于中美比较[J].卫生经济研究,2025,42(01):57-60.
　FANG Zijin,TANG Wenxi,PENG Qian,et al.Design of Medical Insurance Payment Models for Integrated Health Service Organizations ——Based on a Comparison between China and the United States[J].Journal Press of Health Economics Research,2025,42(01):57-60.
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整合型健康服务组织医保支付模式的设计
——基于中美比较
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卫生经济研究[ISSN:1004-7778/CN:33-1056/F]

卷:
42
期数:
2025年01期
页码:
57-60
栏目:
他山之石
出版日期:
2025-01-07

文章信息/Info

Title:
Design of Medical Insurance Payment Models for Integrated Health Service Organizations
——Based on a Comparison between China and the United States
作者:
方子衿1; 唐文熙1; 彭 倩1; 李泯霖1; 耿立影1
1.中国药科大学国际医药商学院，江苏 南京 211198
Author(s):
FANG Zijin;  TANG Wenxi;  PENG Qian;  LI Minlin;  GENG Liying
School of International Pharmaceutical Business, China Pharmaceutical University,Nanjing Jiangsu 211198, China
关键词:
整合型健康服务组织; 医保支付模式; 美国健康管理组织
Keywords:
integrated health service organization;  mecdical payment model;  health management organization in the United States
分类号:
R19
文献标志码:
A
摘要:
美国的健康管理组织（如HMO、ACO、PCMH）开展医保与医疗的深度整合，以效率为导向的医保支付设计兼顾费用控制、医疗质量、医防融合与患者流向引导，在世界范围内具有批判性借鉴意义。我国的整合型健康服务组织（如深圳罗湖城市医疗集团、三明尤溪县域医共体、天津基层数字健共体）的医保支付模式，在费用控制、服务质量、分级诊疗方面都有良好表现，但在提升患者体验、改善人群健康方面略显不足。未来的医保支付应以健康产出为引领，从总额控制转向疾病精细管理，基于循证医学证据探索慢性病目标制绩效支付方式。
Abstract:
Health management organizations in the United States (such as HMOs, ACOs, and PCMHs) have carried out in-depth integration of health insurance and healthcare, and their efficiency-oriented medical insurance payment design takes into account cost control, quality of healthcare, integration of healthcare and prevention, and guidance of patient flow, which is of critical reference significance in the world. The medical insurance payment models of integrated health service organizations in China (such as Shenzhen Luohu City Medical Group, Sanming Youxi County-level Medical Community, and Tianjin Primary Digital Healthcare Community) have performed well in terms of cost control, quality of service, and hierarchical diagnosis and treatment. However, there are slightly insufficient in enhancing patient experience and improving population health. In the future, medical insurance payment should be led by health output, shift from total control to fine disease management, and explore the target-based performance payment method for chronic diseases based on evidence-based medicine.

参考文献/References:

[1] 柏杨，祝贺，马晓晨，等.美国卫生体系整合模式探索及其对我国的启示[J].中国卫生政策研究，2020，13（02）：46-52.
[2] Pati S,Shea S,Rabinowitz D,et al.Health expenditures for privately insured adults enrolled in managed care gatekeeping vs indemnity plans[J].Am J Public Health,2005,95(02):286-291.
[3] 刘锁，高欢，项莉.美国整合医疗服务模式演进对我国医联体建设的启示[J].现代医院，2021，21（10）：1604-1606.
[4] 孙辉，王海银，谢春艳，等.美国以价值为导向的医保支付模式应用及启示[J].卫生经济研究，2020，37（06）：24-27.
[5] Jackson G L,Powers B J,Chatterjee R,et al.The patient centered medical home[J].A Systematic Review.Ann Intern Med,2013,158(03):169-178.
[6] Maeng D D,Khan N,Tomcavage J,et al.Reduced acute inpatient care was largest savings component of Geisinger Health System's patient-centered medical home[J].Health Aff (Millwood)，2015,34(04):636-644.
[7] 姚常芳.城市医疗集团迈向“紧密”[EB/OL].（2023-02-22） [2024-03-02].https://www.szlhyy.com.cn/info/1003/9990.htm.
[8] 福建省医疗保障局.三明市C-DRG收付费政策改革[EB/OL]. [2024-01-10]. https://ybj.fujian.gov.cn/xwzx/sxyw/201801/t20180110_47 77994.htm.
[9] 天津市医疗保障局，天津市卫生健康委.关于全面推行糖尿病门诊特定疾病按人头总额付费有关工作的通知[EB/OL].[2024-01-17]. https://ylbz.tj.gov.cn/xxgk/zcfg/ybjwj/202202/t20220216_5805343.html.
[10] 李陈晨，王芳，薛婉君.美国整合卫生保健主要做法及启示[J].中国卫生经济，2014，33（08）：90-93.
[11] 许怀湘.美国医保支付方式的演变及对中国医保支付改革的启示[J].中国医院，2012，16（09）：69-72.
[12] 朱晓丽.美国基于整合医疗服务的医保支付方式改革经验及启示[J].中国物价，2019（01）：89-91.
[13] 朱晓丽，郑英，王清波，等.我国部分地区医联体医保总额预付制改革的比较分析[J].中国医院管理，2020，40（02）：21-25.
[14] 杜雯雯，徐伟，刘萍，等.美国责任医疗组织医疗质量评价体系对我国医共体按人头付费结算考核的启示[J].中国卫生经济，2022，41（04）：92-96.
[15] 胡琦，吴方，任旭，等.美国、加拿大两国以患者为中心的基层卫生服务模式比较与启示[J].中国社会医学杂志，2023，40（02）：204-208.

更新日期/Last Update: 2025-01-07