医保支付约束激励公立医院优化递送体系研究

Since the New Health reform, the majority of Chinese population has been covered by the new basic health insurance system.It has become fundamentally important to incentivize public hospitals by payment system,which determines the efficiency of health care delivery system and the performance of holistic stakeholders. This project will focus on designing optimal payment system to push public insurers to solve the shopping problem of patients as the third party by bargaining with public hospitals and motivate providers to pay intensive attention on prevention and primary care and provide scientifically appropriate care instead of making profit by overprescribing or cross-subsidizing care by selling drugs. We would like to offer a Chinese version of payment system with function rengeneration which is favorable to primary care and beneficial to vulnerable patients especially those with catastrophic diseases.The new payment system is intended to incentivize public hospitals to give up collusion with patients, cure the patients with efficent synergy instead of competing for patients,ultimately evolving into an inovative health care delivery systen with triage for different tiers of providers with ‘bottom to top’ flow for patients and ‘top to bottom’ flow for physicians and push the New Health Reform.

新医改以来快速实现的基本医保全覆盖，凸显出医保支付制度对公立医院的约束激励良性运作的重要性。支付制度合理与否决定着医疗递送体系的优化和医改整体效果的优劣。本项目旨在密切结合全民医保的国情和实践，研究深化发挥医保机构作为第三方代表广大患者解决“选购难题”的独特作用，强化其在购买服务时的主动性和“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的惯常做法，使靠科学提供、恰当医疗、靠运作效率提高、关注健康保障和医疗重心梯度下沉成为其运作常态和“营收主战场”。探索令各利益相关者均能接受，亲基层、救大病、惠弱势“中国版本”支付制度的“功能再造”，使之约束激励公立医院有动力将“医患合谋”、不同级别医疗机构 “争抢患者”的竞争对立转化为 “治好患者”的高效协同，实现各层级医疗服务提供分级诊疗的模式创新，形成患者梯度上移，医务工作者梯度下移的医疗服务格局，推进新医改。

健康新时代，新技术不断涌现，政策迭次出台，各利益主体观望、调适、多方博弈，改革充满了不确定性。.本研究事关民众医疗健康，过程复杂、难度颇高。团队抓住核心问题，知难而进，取得了系列研究效果：.总额预付制的效果；关注医疗总量提升背后的质量下滑；分级诊疗下居民就医选择的影响因素尤应完善相关激励机制和医保精细化管理、提升基层的软硬实力、加强政策宣传引导居民形成科学的就医习惯等；.针对基层医疗的软实力六个维度：患者被尊重程度、医务人员工作责任感、医务人员服务态度、医务人员给予解释和交流的情况、医疗人员技术水平和信息公开情况；硬实力五个维度：患者到基层就诊的方便性、就诊环境、医疗设施、医疗设备以及药物丰富性等调研实证；.探讨了医联体的动力机制，医疗联合体建设“要”在强基层的推进方略；实证医联体内基层医疗发展状况，评价医联体的推动是否真正带来基层医疗本质上的提升；强基层的医疗联合体转诊制度设计以及基于动态最优控制模型的质量创新与过程创新研究；典型医联体、家庭医生制度等能实现健康中国目标的强化基层医疗的机制设计原则和方案； .基于地域差异实证研究医药分开对医疗费用的影响：药占比下降，人均医疗费用反而升高；药品费用和药占比呈正相关，检查治疗费用和药占比呈负相关；异质性分析发现医药分开的实施效果在中部地区实施效果比西部地区差等；.医保支付与参与主体博弈分析；健康中国战略下医保支付制度的“初心”和“使命”；探究医保支付对医联体注重预防、关注健康、有效分流患者的强化基层的资源优化配置机制；.城市分级诊疗的医院和基层医疗机构利润模型；约束激励不同级别机构由“医患合谋”、“争抢患者”转化为协同“治好患者”的发展动力机制、高效协同机制和利益分享机制；.结合不同地域不同发展阶段，审慎探索政府和市场的作用方式、范围以及互补共赢模式，探讨二者科学有机结合、协力促进治理体系和治理能力现代化，共同助力健康中国战略梦圆的发展方略。