医保支付制度对利益相关者作用机理及整体优化机制研究

From Health Care Reform till now, all the citizens in China have been covered by the new health care system. The success for the reform of healthcare payment system will be the key to the sustainable development of health care system and have much influence on the benefit of physicians and patients as well as health organizations, also have much influence on the success of the whole new health care reform. The project will focus on healthcare payment system design which will be suitable to China's situation based on health care and put a higher priority of prevention and optimize health resources. It will summarize and review the useful ingredients from international and domestic health management and care, positive interaction between community health centers and hospitals, incentives and models of healthcare payment system with system theory, mechanism design theory, health economics,experimental economics,etc.; deeply analyze the mechanism of healthcare payment system on stakeholders; closely combine with the pilot practice and effect of domestic healthcare payment system; seek or create the holistic opimization models and mechanisms which will be equipped with characteristics of gradual optimization,win-win,positive interaction for stakeholders' long run benefit and also lead into the health organizations' transition from illness-oriented to human-oriented and also realization of value, resposibility and revenue as well; moderate selective freedom for patients who could sufficiently and moderately make use of services from community health centers and hospitals; The healthcare payment system holistic optimization model with Chinese charateristics would definitely promote the level of national healthcare and sustainable development of the New Health Care System in China.

医改至今，基本医保几乎全覆盖了全体国民，医保支付制度的改革成败将决定医保制度的可持续发展和医患的切身利益，甚至决定新医改整体的成败。本项目旨在密切结合国情，建立基于健康保障、强调预防为主的资源优化的医保支付制度。运用系统论、机制设计理论、卫生经济学、实验经济学等理论，总结提炼国内外健康管理与保障、社区卫生与高等级医院良性互动、支付体系激励和模式等的合理成份，深入剖析医保支付制度对利益相关者的作用机理，密切结合国内支付制度改革试点的实践和效果，寻求符合各利益相关者长期利益逐步优化、多赢、良性互动的整体优化模式和机制，令不同层次医疗机构从"以病为本"向"以人为本"转换，实现各就其位、各尽其责、各得其利；患者择医自由度适中，能充分和恰当运用社区卫生服务和高等级医院的医疗服务；实现符合中国国情、具有中国特色的医保支付制度整体优化模式，以期更好地实现国民健康水平的提升和新医改制度的可持续发展。

我国基本医保制度已实现全覆盖，支付制度已成为整个医疗资源配置的指挥棒，对支付制度对利益相关者的作用机理和整体优化机制深入研究，是能否实现公平与效率、有效控制医疗费用过度增长的至要法宝。.本项目以满足广大民众的多层次医疗需求为出发点，正视发展历史和现实制度背景、演化机制和内外在的约束条件，将支付制度放在医保制度发展和“三医联动”大局中来考量、谋划和设计，从探求医保支付制度对利益相关者作用机理和整体优化机制的视角，研究促进医疗服务提供与消费“梯度有序”的“正三角”资源优化配置格局形成的支付制度。.研究表明：.因医保支付制度允许患者具有过大的择医自由权，集体冲向高端医疗机构直接就诊，致使高端医疗机构对错位来就医的小病患者仍可以获得丰厚或有利的回报，令医疗机构的着力点不可能回归到疾病预防、健康维护和恰当医疗，本已极度稀缺的高端资源被无谓浪费。.采取“看门人”制度或有效的分级诊疗是必须的选择，强化基层医疗服务是必然的选择。旨在尽快提升基层医疗服务能力、实现“患者梯度上移、医务工作者梯度下移”宏愿的原本设计的医疗联合体，唯有通过医保支付制度的预付改革和政府的有效监管等才可能奏效。.主张：.（1）通过医保支付制度的调整，强化医疗保险在购买服务时的“团购优势”，逼使医疗服务供方放弃或弱化靠“以药养医”、靠检查养医、靠治疗创收等价值取向。使靠科学提供、恰当医疗、靠运作效率提高和关注健康保障，靠医疗重心梯度下沉成为医疗服务提供方高效运作和可持续发展的常态；.（2）靠差异化的支付激励使需方形成科学的消费习惯、梯度上移的消费行为；.（3）通过以上二者的“合力”，设计充分调动各级医疗机构更好地关注人群健康，充分利用社区卫生服务和恰当运用高等级医疗服务、患者能理性合理消费的医保支付制度，优化资源配置。.（4）支付制度梯阶累进支付无封顶大病保险存在隐忧。