医保支付之限额付费方式——基于湖南蓝山、桑植两县的调查

医疗保险支付方式是医疗保险机构对医、患(参保人)的付费方式。支付方式改革是当今世界很多国家医改的核心与难题。湖南蓝山县和桑植县推行了限额付费方式改革,参合农民在乡镇卫生院看病就医,门诊、住院费用付费限额内如实自付,超额部分由新农合基金全额报销,同时,对卫生院实行诊疗人次费用、住院床日费用以及总费用控制,对医生实行绩效工资制。创造了有别于"全民免费医疗"的"全民限费医疗"新模式。推广这种新模式的路径是:明确医疗服务的享受主体、服务主体及范围,科学制定总额预付标准,完善监管机制,建立医疗服务与社会医疗保险二位一体的新体制等。

On Ceiling Payment Pattern of Health Insurance, Based on the Research of Lanshan County and Sangzhi County, Hunan Province

Health insurance is the principal part of medical security. The payment pattern of health insurance is the way how the medical insurance institutions, as the subjects of payment, insure those insured against losses due to ill health. Its game strategies with the hospital, the patient and the insurance institution interact as cause and effect. The reform in payment pattern is the core and puzzle of health care reform in many countries today. In pace with the establishment and development of social medical insurance system over the past 10 years, China has been exploring and reforming the payment pattern of health insurance but bears no satisfying fruit. In 2011, Sangzhi County and Lanshan County of Hunan province highlighted the reform in the payment which, health centers in villages and towns charge the insured patients within pattern of those insured, according to certain limits, namely, insured patients pay for the fees within the limits while the new rural cooperative fund cover the exceeding ones. This created a new mode of ＂limited cost for medical service＂ other than ＂no cost for medical service＂. Meanwhile, the reform in the payment pattern of the hospital is on the march. The cost for each patient＇ s visit, each bed per day and the total cost of the health center is under control and doctors are paid based on their performance. It has been proved that ＂limited cost for medical service＂ is likely to pave the new way for China＇s universal health care, and is necessary to be popularized by reform in system and mechanism.