紧密型县域医共体下人头总额预付与DRG付费协同机制研究：基于整体性治理视角
he Synergistic Mechanism of Capitation Prepayment and DRG Payment in Compact County-level Medical Consortium：from the Perspective of Holistic Governance
背景 我国各地积极推进紧密型医共体医保总额预付支付方式改革，但医共体内部疾病诊断相关分组（DRG）/病种分值付费（DIP）支付和总额付费政策融合仍处于探索阶段，虽已有研究从复合型医保支付方式的控费效果与控费机制进行研究，但仍有可拓展之处。目的 了解紧密型医共体下人头总额预付与DRG支付政策的协同机制与成效。方法 于2023年7月，赴殷都区开展实地调研，采用便利抽样法抽取紧密型医共体内关键知情人进行半结构化访谈（n=28），访谈提纲涉及医保支付改革政策与措施、激励机制、工作感知及优化建议等。根据整体性治理理论，采用主题框架分析法对访谈资料进行分析，以搭建殷都区紧密型医共体人头总额预付和DRG付费的协同机制框架。同时检索2017年1月—2024年7月发布的与殷都区医共体建设和医保改革等密切相关的政策文件（n=18），以补充相关政策背景信息。结果 形成以政策行为、监督行为、服务行为、激励机制4个分析主题，覆盖12个子主题的主题框架。医保支付改革在紧密型医共体治理框架中起关键引导作用，人头总额预付与DRG付费存在先后的依从关系。医共体内人头总额预付与DRG付费的协同机制是通过互相补充、完善政策行为、监督行为和对服务行为的激励机制实现的，对于在紧密型医共体中实现资源整合和“以健康为中心”的目标，二者均不可或缺。结论 在紧密型医共体内，同时推进人头总额预付与DRG付费方式改革通过构建整合机制和激励机制，能够发挥政策合力，影响政策行为、监督行为以及各级医疗机构的服务行为，共同推动实现“以健康为中心”的服务目标。
BackgroundAll regions in China are actively promoting the reform of the prepaid payment method for the total amount of medical insurance in the context of the integrated medical community. Howeverthe integration of DRG/ DIP payment and the total amount payment policy within the integrated medical community is still in the exploratory stage. Although there have been studies on the cost control effect and cost control mechanism of the composite medical insurancepayment methodthere is still room for expansion. ObjectiveTo analyze the synergistic mechanism and effects of capitation prepayment and DRG payment in the compact county-level medical consortium. MethodsIn July 2023a field survey was conducted in Yindu District. The convenience sampling method was used to select key informants within the integrated medical community for semi-structured interviewsn=28. The interview outline covered medical insurance payment reform policies and measuresincentive mechanismswork perceptions and optimization suggestionsetc. Based on the holistic governance theorythe thematic framework analysis method was used to analyze the interview data to build a coordination mechanism framework for the prepaid payment for the total number of people and the DRG payment in the integrated medical community in Yindu District. Meanwhilepolicy documents closely related to the construction of the integrated medical community and medical insurance reform in Yindu District published from January 2017 to July 2024 were retrievedn=18 to supplement relevant policy background information. ResultsA thematic framework with 4 analytical themesnamely policy behaviorsupervision behaviorservice behavior and incentive mechanismcovering 12 sub-themes was formed. The medical insurance payment reform plays a key guiding role in the governance framework of the integrated medical community. There is a sequential compliance relationship between the prepaid payment for the total number of people and the DRG payment. The coordination mechanism between the prepaid payment for the total number of people and the DRG payment within the integrated medical community is achieved through mutual supplementationimprovement of policy behaviorsupervision behavior and the incentive mechanism for service behavior. Both are indispensable for realizing resource integration and the goal of "health-centered" in the integrated medical community. ConclusionIn a Compact medical communitycapitation prepayment and DRG payment systemsby establishing integration mechanisms and incentive structurescan synergize policy effortsinfluence policy implementation behaviorsoversight activitiesand the service delivery practices of healthcare institutions at all levels. Togetherthese factors contribute to the achievement of a "health-centered" goal.
陶红兵、边颖、张梓洵、尹刚
医药卫生理论
紧密型县域医共体人头总额预付RG 付费整体性治理医保支付方式
陶红兵,边颖,张梓洵,尹刚.紧密型县域医共体下人头总额预付与DRG付费协同机制研究：基于整体性治理视角[EB/OL].(2025-01-24)[2025-08-22].https://chinaxiv.org/abs/202501.00235.点此复制
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