基层医疗体制机制与医疗保险付费方式的适配性研究

Suitability of basic medical system and medical insurance payment method is related to the success or failure of basic medical and health system reform,and exercises a great influence on the development of basic medical and health undertakings. under the situation of comprehensively deepen reform launched by the Central Committee of the Communist Party of China, based on the public policy and local practice of Grassroots Health Reform in China,this topic will answer three problems that grassroots medical institutions and mechanisms the medical insurance payment method why to \how to\whereby suite, in view of the the mismatch of grassroots medical institutions and mechanisms and medical insurance payment methods, with the subject of the suitability of grassroots medical institutions and mechanisms and medical insurance payment method .The main content of this topic include: building suitability theory of grassroots medical institutions and mechanisms and medical insurance payment methods, and then analyzing the suitability condition of grassroots medical institutions and mechanisms and the medical insurance payment method,and finally putting forward the suitability path of grassroots medical institutions and mechanisms and the medical insurance payment method, in ord to provide theoretical reference and policy suggestions for the coordinated reform of grassroots medical institutions and mechanisms and medical insurance payment method .

基层医疗体制机制与医疗保险付费方式的适配性，关系基层医药卫生体制改革的成败，影响基层医疗卫生事业的发展。在中共中央全面深化改革的形势下，本课题立足于我国基层医改的公共政策和地方实践，针对基层医疗体制机制和医疗保险付费方式的错配化困境，以基层医疗体制机制与医疗保险付费方式的适配性为主题，解答基层医疗体制机制与医疗保险付费方式"为何"、"如何"、"以何"适配3个问题。本课题的主要内容包括：构建基层医疗体制机制与医疗保险付费方式的适配理论，然后评价基层医疗体制机制与医疗保险付费方式的适配状况，最后提出基层医疗体制机制与医疗保险付费方式的适配路径，为我国基层医疗体制机制和医疗保险付费方式的协同改革提供理论参考和政策建议。

医疗服务供给和筹资的制度错配，是当前我国医药卫生事业发展的现实困境；构建供给和筹资体系适配的制度组合，是当前我国医药卫生体制改革的迫切任务。本课题分析了公立医疗体制机制与医疗保险付费方式的适配现状，构建了公立医疗体制机制与医疗保险付费方式的适配理论，建言了公立医疗体制机制与医疗保险付费方式的协同改革。一是凝练出国外医疗服务体制机制与医疗保险付费方式的五大适配理论，即政府购买服务理论、有管理的竞争理论、花钱矩阵理论、责权利均衡理论、激励相容理论；总结出国内医疗服务体制机制与医疗保险付费方式的四大适配理论，即三医联动理论、供给主导理论、需求主导理论、权变策略理论。二是提出了医疗服务体制机制与医疗保险付费方式适配的一个根本要求和三个基本标准,即体制兼容是医疗服务体制机制与医疗保险付费方式组合的根本要求,功能分工、功能协同和功能互补是医疗服务体制机制与医疗保险付费方式组合的三大标准。三是提出了公立医疗体制机制与医疗保险付费方式的两个适配组合，即公立医疗绩效型行政化体制与医疗保险后付费方式的制度组合、公立医疗治理型市场化机制与医疗保险预付费方式的制度组合。四是提出了公立医疗体制机制与医疗保险付费方式的两个错配组合，即公立医疗绩效型行政化体制与医疗保险预付费方式的制度组合、公立医疗管制型市场化体制与医疗保险预付费方式的制度组合。五是梳理了医疗保险付费方式与公立医疗体制机制的关系，即医疗保险付费方式与医疗质量保障的关系、医疗保险付费方式与医疗费用控制的关系、医疗保险付费方式与医疗成本控制的关系、付费方式的联动改革与医疗服务的供求均衡、医疗保险按人头付费与医疗体系健康管理的关系、医疗保险付费方式与基层医疗资源配置的关系、医疗保险付费方式与医疗服务价格的关系。研究成果丰富了相关理论，融入了政策实践，受到了社会好评，获得了省部级成果奖。