CAJ | 학술논문

目的：针对总额预付制度下，政府确定合理医保总额难度大的问题以及医疗机构存在少收医保患者、降低服务质量等现象，探索全科医生按人头医保全口径预付管理方案的模式架构。方法本研究采用理论研究与实证研究相结合的方法，通过借鉴国外成熟的医保费用控制经验和理论及充分吸收国内研究机构的相关研究成果，探索适合我国国情和医疗卫生发展需要的合理控制医保费用的方法和措施。结果拟建立起以主要在社区卫生服务中心就诊的签约居民为预付对象，以签约全科医生为责任人，以社区临床路径为管理工具，以疾病控制达标率、成本管理合理性和签约对象满意度为判断标准的按人头医保全口径预付管理方案，形成符合客观现实的模式架构。结论可尝试通过全科医生家庭签约服务制，按人头医保全口径预付管理，实现全科医生“守健康、守费用”，使其真正成为社区居民健康的守门人。此模式尚不成熟，还需实践进一步证实。
목적：침대총액예부제도하，정부학정합리의보총액난도대적문제이급의료궤구존재소수의보환자、강저복무질량등현상，탐색전과의생안인두의보전구경예부관리방안적모식가구。방법본연구채용이론연구여실증연구상결합적방법，통과차감국외성숙적의보비용공제경험화이론급충분흡수국내연구궤구적상관연구성과，탐색괄합아국국정화의료위생발전수요적합리공제의보비용적방법화조시。결과의건립기이주요재사구위생복무중심취진적첨약거민위예부대상，이첨약전과의생위책임인，이사구림상로경위관리공구，이질병공제체표솔、성본관리합이성화첨약대상만의도위판단표준적안인두의보전구경예부관리방안，형성부합객관현실적모식가구。결론가상시통과전과의생가정첨약복무제，안인두의보전구경예부관리，실현전과의생“수건강、수비용”，사기진정성위사구거민건강적수문인。차모식상불성숙，환수실천진일보증실。
Objective To explore the pattern and framework of the management plan of full - caliber health insurance prepayment plan managed by general practitioners according to the number of patients,in order to provide solutions for the problems like difficulty of government in determining the total amount of health insurance,the reluctance of medical settings to admit patients with health insurance and poor service quality of medical settings for patients with health insurance. Methods In this study,we adopted the combination of theoretical research and empirical research method. Through referencing the foreign experience of health insurance cost control and absorbing the research results of domestic research institutions,we explore methods and measures for the reasonable control of health insurance cost appropriate for China's national condition and the needs of health development. Results A management plan of full - caliber health insurance prepayment by the number of patients was built,with the signed residents who received treatment in community health service centers as prepayment objects,signed general practitioners as persons in charge,community clinical pathway as management tool,and with the standard - reaching rate of disease control,the rationality of cost management and the satisfaction degree of patients as criteria,thus a mode according with objective reality was formed. Conclusion Health insurance full - caliber prepayment by the number of patients under GP contract - signing family service system can be tried,so as to make general practitioners become the real gatekeepers of community health services. However,the mode is not mature yet,which needs further verification.