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Text . . . Zhang Zhongfang's medical insurance payment method, as a powerful lever to allocate medical resources, can regulate the medical treatment behavior of the insured and the medical institutions and doctors' diagnosis and treatment behavior to a certain extent, thus playing a certain role in promoting the graded diagnosis and treatment.
Despite the country's success stories, there is a need to look rationally at the role that health-care payments can play.
medicare payment methods include both the payment method for the needer (i.e. the insured) and the payment method for the supplier (i.e. the medical service).
to promote graded diagnosis and treatment should also start from both the insured and the medical service institutions.
the way to pay for health insurance for the insured includes the starting line, co-payment ratio, the maximum amount and so on.
to promote graded care, local health insurance departments usually set lower starting lines and higher reimbursement rates for primary-level patients, hoping to channel patients to primary health care institutions through financial incentives.
this kind of economic incentive is widely used in various places, but the effect is not obvious, the main reasons are two: First, the insured people have long formed the concept and habits of medical treatment, regardless of the big illness and small diseases are more willing to run to the big hospital; In addition,
, some areas have explored the implementation of mandatory or semi-mandatory community gatekeepers.
such as Qinghai Province to implement compulsory first consultation and step-by-step referral system, the insured must go through the approval of the primary first medical institution in the hospital, in order to step up the referral;
While administrative coercion is more effective than economic incentives, it may also trigger popular discontent.
for the supply side, the main way of payment for medical insurance is to pay by service, pay per head, the total budget system, according to disease diagnosis related group payment.
scientific and reasonable way of fee settlement can curb the induced demand behavior of medical institutions, and help promote the reform of three-medical linkage and graded diagnosis and treatment.
for example, Luohu District, Shenzhen, Guangdong Province, the use of the "medical community" hospital group model, through the sinking of high-quality medical resources into the social health center, to solve the problem of lack of medical care at the grass-roots level, while the implementation of "pay-per-head" health insurance payment reform, for hospitals, the fewer patients balance the more funds, greatly enhance the enthusiasm of medical staff to people's health management.
they actively enter the community, provide health guidance for chronically ill patients, and prevent accidental risks.
, such as Zhanjiang City, Guangdong Province, the implementation of the pay-per-disease settlement, the hospital classification, disease classification, such as hospitals admitted to patients who do not match the level of hospital treatment, medical insurance payments will be discounted, from the medical institutions to promote graded diagnosis and treatment.
in fact, in order to truly achieve graded diagnosis and treatment, the most fundamental way is to strengthen the construction of primary medical institutions.
only when the level of medical treatment at the grass-roots level is improved and the medical environment improves, the insured people will be willing to seek medical treatment.
, the author believes that the current common and chronic diseases are the main content of outpatient services, can appropriately adopt mandatory or semi-mandatory way to guide the insured to the community or grass-roots medical treatment, one can promote graded diagnosis and treatment, reduce the pressure of large hospitals, the other can save health insurance funds, in the increasingly serious situation of aging to ensure the sustainable development of health insurance funds.
inpatient medical services are often targeted at some patients with urgent or serious conditions, in the current primary medical institutions in the case of poor medical capacity, it is more appropriate to use economic incentives to guide patients to choose medical treatment.
promoting graded diagnosis and treatment is one of the core objectives of "new medical reform", and the reform of medical insurance payment method can promote graded diagnosis and treatment to a certain extent, promote the effective allocation of medical resources, and enhance the accessibility and fairness of medical treatment and fairness of the insured.
in this process, always follow the "people's health first" mission, and strive to achieve the ultimate goal of health for all.
original title: Rational view of the role of health insurance payment in promoting graded diagnosis and treatment.