新型农村合作医疗门诊总额预付支付方式研究
|
摘要
一研究背景
新型农村合作医疗(以下简称“新农合”)实施之初是以大病统筹为主,随着筹资水平和住院补偿水平的提高,门诊家庭账户地区开始向门诊统筹转变。2008年,国务院召开全国新型农村合作医疗工作会议提出政策导向,推行门诊统筹。截止2009年底,全国实施门诊统筹地区己达三分之一。
根据卫生部卫生统计年鉴数据,我国2009年较2003年人均卫生总费用年均增长率为16.09%,人均医疗费用年均增长率为19.49%。从医疗总费用的构成来看,在全国范围内门诊费用通常要占到总医疗费用的65%以上,且比重还有增长的趋势。医疗费用的高速增长已经成为医保面临的严峻形势和挑战,新农合门诊也不例外。随着门诊统筹开展及医疗费用的不断增长和补偿水平的提高,部分地区出现了门诊基金超支风险,尤其在实施门诊统筹之后带来的就医需求的巨大释放给新农合门诊统筹顺利开展带来了巨大的挑战和考验。在一定筹资水平下,适宜的支付方式是控制医疗费用,维持基金平衡的重要手段,因此从控制医疗费用和新农合基金平衡的角度亟需对门诊支付制度展开的研究。
在目前支付方式中,控费效果最好的是总额预付,很多地区已经开始采用这种支付方式,相关部门也在积极提倡。卫生部在《关于落实2010年医改任务做好农村卫生服务有关工作的通知》中提出,在开展门诊统筹的地区,积极开展门诊总额预付等支付方式的改革。从费用控制和政策研究的角度来研究门诊总额预付具有十分重要的现实意义。在现有的总额预付研究中,涉及新农合门诊总额预付的研究有限且深度不够,因此从理论研究方面也具有十分重要的意义。
本研究结合实际调查的结果,探讨在现有筹资水平下,如何开展新农合门诊总额预付,为新农合门诊总额预付实施提供参考依据。
二研究目的与内容
(一)研究目的
通过对当前门诊统筹支付方式现状研究,结合总额预付理论分析和实践经验,研究和探讨在农村基层医疗机构实施门诊总额预付的测算办法、实施条件和监管机制,为完善新农合门诊支付制度、促进新农合的可持续发展提供依据。
(二)研究内容
1分析样本地区新农合制度实施情况,重点总结其门诊支付制度现状及存在问题。
2分析新农合门诊现有总额预付的测算方式、实施条件及其运行机制,提出适应我国新农合现状的测算方法和运行机制。
3对安徽省南陵县进行典型案例分析,根据本研究测算方法进行门诊预付总额测算,并在实施一年后分析其实施效果,总结存在的问题并提出相应对策。
4根据现状研究和典型案例研究结果与分析,提出针对新农合门诊总额预付的测算方法和实施条件的建议。
三研究方法
(一)资料来源
1样本地区的选择
根据经济发展水平,兼顾地区分布,选择门诊统筹已经实施1年以上(最好是已经实施门诊总额预付的)的县(市、区)作为研究对象,所选10个样本地区为江苏省张家港市和句容市、安徽省肥西县和南陵县、陕西省临潼区和旬邑县、云南省寻甸县和澄江县、上海市南汇区和重庆市黔江区。
2资料收集方法
本研究在2009年下半年进行一次现场调查,在2011年初收集安徽省南陵县2010年新农合门诊基本数据进行分析。具体资料收集方法主要有问卷调查,二手资料收集,关键知情人访谈。
(二)分析方法
本研究所用的分析方法有文献归纳法,医疗保险费的粗估法,PETS可行性分析法和典型案例研究法；用到的分析工具有Excel2007、SPSS11.5。
四研究结果
(一)主要研究结论
1样本地区门诊统筹现状
(1)样本地区新农合总体状况和存在问题
10个样本地区新农合总体处于良好的发展阶段,主要体现在以下五方面。一是参合率逐年提高；二是筹资水平年增长率在25%左右,多数样本地区个人筹资额占当年农民人均纯收入的0.01%一0.02%之间；三是新农合基金结余总体较稳定；四是住院受益面逐步扩大,受益程度逐年加强；五是截止到2008年,家庭账户已全部转变为门诊统筹,参合群众受益面扩大。
新农合运行中也存在很多不足之处。一是新农合次均住院费用增长速度较快给新农合基金运行带来了极大的风险；二是门诊统筹基金超支和结余情况差异较大,门诊统筹基金科学测算、门诊费用控制和监管难度较大；三是门诊统筹总体处于开始阶段,目前门诊实际补偿比例偏低,对参合农民的吸引力不是很大；四是实际调研中个别地区反映门诊报销手续复杂,给乡村医生增加很多工作量。
(2)样本地区门诊总额预付总体状况和存在问题
截止到2009年,10个样本地区己全部实施门诊统筹,有5个样本地区实施门诊总额预付。己实施门诊统筹地区门诊基金划分比例在20%-40%之间,上海市南汇区划分比例较高,占基金筹资总额的.43.4%；现有门诊总额的测算方法主要是按照服务量测算和按照人头测算两类,两种测算方法存在一定合理性,但总体上考虑因素简单；在年终弹性结算方面,总体遵循“超支不补,结余归己”原则；除上海南汇区覆盖三级卫生网络外,总额预付多覆盖乡村两级医疗机构；上海市南汇区实施总额预付度后,次均门诊费用下降32.14%,降低门诊医疗费用的效果十分明显。
门诊总额预付存在问题为：一是门诊基金收支不平衡；二是门诊总额测算方法简单,考虑因素不足；三是年终弹性结算方法有待完善；四是中西部地区门诊信息系统不健全,给门诊总额预付测算、监督考核都带来了很大困难。
2门诊总额预付支付方式探讨
门诊总额预付方案的设计主要应遵循量入为出和保障基本医疗原则、合理补偿供方原则、可行性原则、相对稳定与适时变动四个原则。建议新农合门诊基金分配占年度统筹基金的20%-30%左右。在筹资增加的基础上,逐年提高新农合门诊统筹基金占总基金的比例。
目前总额预付测算方法分为成本测算法、点数法、按实际测算法、按服务量测算法和按人头测算法五种。
根据对医疗保险费的粗估法探讨,结合我国新农合门诊现状,归纳出适合我国新农合门诊的总额预付测算方法,其公式为：
其中：M为门诊预付总额；A为次均门诊费用标准,在次均费用差别较大时,可以根据实际情况,结合医疗机构服务能力和经济发展水平对医疗机构进行费用分层；S(S=门诊利用率p×服务人口数Popu)为门诊服务量预测值,在服务人口一定的情况下,对门诊就诊率较低的医疗机构可以适当放宽,对门诊利用率较高的医疗机构适当从严；R为实际补偿比；C为增长系数；F为保险因子;i代表县级医疗机构；j代表乡级医疗机构；k代表村级医疗机构；n为县级医疗机构个数；m为乡级医疗机构个数。
门诊总额的测算是一个前瞻性的预测,其实际值受诸多因素影响,为降低不可预测性因素影响,建议年终实施弹性结算。首先确定超支与结余的合理性。对于不合理的超支和结余,应进行一定的处罚。合理超支时,把超支部分的60%-75%补偿给医疗机构,作为对其医疗成本的弥补；结余时,当门诊预付总额结余额≤节省的门诊医疗费用×(25%-40%)时,结余全部归己；当门诊预付总额结余额>节省的门诊医疗费用×(25%-40%)时,其中未超出部分归己。对于不合理的超支和结余要加以惩罚。
监督考核方面建立公示、考核和监督体系,建立考核的指标体系,考核结果与绩效挂钩。实施新农合门诊总额预付两个基本条件是建设覆盖三级卫生网的信息系统和实施乡村一体化管理。
3安徽省门诊总额预付典型案例分析
安徽省南陵县满足实施门诊总额预付的基本条件,根据本论文提出测算公式,以安徽省南陵县2009年数据为基础,测算其2010年基础门诊总额536.35万元,增长系数为1.087,调整后的2010年安徽省南陵县三级医疗机构的门诊预算总额为583.01万元。2010年门诊基金实际支出为546.97万元,总额测算结果仅比实际门诊基金补偿总额多6.52%,由此说明该测算方法比较切合实际基金支出,具有实际应用意义。同时对2009年和2010年门诊数据对比发现,门诊总额预付很好的控制了门诊总费用,控制了门诊医疗费用的过快增长的同时保证门诊基金收支平衡,促进门诊服务的利用,提高了群众受益程度。
(二)讨论
1弹性结算依据
由于数据限制,年终弹性结算中对劳务成本的结算是仅对乡村医生的收入结构进行粗略分析,缺乏对乡级和县级医疗机构的成本结构分析。
2总额测算方法讨论
在对门诊总额进行测算时要结合实际相应调整。在存在乡级医疗机构水平差异较大情况下,可根据实际情况,制定不同等级水平的次均门诊费用标准。在实际测算时,对于乡级和村级医疗机构,也可以采用平均实际补偿比来测算,从理论上更体现公平性。
3基本药物制度与总额预付的关系
在典型案例研究中,安徽省南陵县2010年实施了门诊总额预付,同时也实施了基本药物制度零差价制度。从理论方面分析,基本药物零差价和门诊总额预付都可以降低门诊费用,因此对于总额预付控费作用还需要长期观察。
(三)建议
1立足现实是新农合门诊总额预付的前提
新农合制度门诊统筹实施要建立在住院补偿水平达到一定程度的基础上,同时有领导重视并具有高素质的新农合管理队伍。同时需要加强政策宣传引导和与医疗机构的沟通。
2信息系统是新农合门诊总额预付的基础
门诊信息系统在门诊费用的收集、统计、即时监管方面起了重要作用。它包括电脑和网络及软件设施,最重要的是电脑操作人员。投入方面建议县级财政为主,鼓励引入社会资本。
3科学测算是新农合门诊总额预付的关键
门诊总额预付是一种前瞻性的预测,影响因素诸多,很容易出现与实际有差距的情况。科学合理的测算门诊总额,一方面要建立在数据信息收集的基础上；另一方面要紧密联系实际。
4弹性结算是新农合门诊总额预付的调节
总额预付的测算是一种前瞻性的测算,弹性结算可以弥补诸多不确定性因素导致的测算不准确的缺陷,给因为服务能力增强而超支的医疗机构一定的成本补偿,对主动控费的医疗机构给予一定的经济激励,对不良医疗行为也给予相应的处罚,是实施门诊总额预付的调剂手段。
5监督考核是新农合门诊总额预付的保障
建立一套系统的监督体系和监督队伍,定期对医疗机构的医疗行为监督考核,是顺利实施门诊总额预付的保障。
【Backgrround】
Since 2003, New Rural Cooperative Medical Scheme (NCMS) has made tre-mendous contributions for Chinese rural health care. At the beginning NCMS mainly aim is "Pooling Funds for Serious Illnesses", with the increase of funding level, the hospital has reached a higher compensation level, most regions already have the ability to pool of out-patient service.
In order to expand the benefit package, NCMS in some areas set up the family account model with the development of NCMS, family account model's drawbacks began to appear, the advantages of pooling of out-patient service is gradually emerg-ing. In 2008, the State Council held a national NCMS work conference, put forword policy guidance, basically denied the family accounts, implemente of outpatient co-ordination. At the end of 2009, the area of outpatient co-ordination has reached one-third in China.
Dependented on the Health Statistics Yearbook data of the Ministry of Health, China's total health expenditure in 2009 compared 2003 with gains of up to 145% in 2003, who received treatment in 2008 compared with 2000 per capita health care costs increased by nearly 71%, the rapid growth of medical costs has become a big challenges for medical insurance system, NCMS is also the same. With increasing of medical expenses and compensation level, some regions have arisen risk of fund cost overruns of out-patient. Although there were small per capita fees of outpa-tient, lower compensation, but it has large quantities. Therefore, from the point of view the NCMS fund balance is also needed a systemic research on the total pre-paid system of out-patient system.
In the current method of payment, the best pament system of controlling expense is global budget, which many regions have begun to apply., but it is has no systematic theoretical research.Ministry of Health, "health care reform in 2010 on the implementation of the tasks of rural health services" put forward "in the proposed areas of co-ordination in carrying outout-patient, carrie out payment reform such as global budegets of out-patient". From the perspective of cost control and policy research to study the global budget of outpatient has great practical significance.
This study combines the actual survey results of the current funding levels, how to launch global budget of out-patient of NCMS, providing reference for NCMS.
【Objectives and Contents】
(a) Objectives
Study the payment of out-patient through analysis current situation, combinated withthe theoretical analysis and practical experience in advance, study and explore the estimation of global budget of out-patient, conditions and regulatory mechanism in primary health care institutions in rural medical institutions, improve the out-patient payment system of NCMS and provide the basis for sustainable development.
(b) Contents
1. Analysis the implementation of NCMS in the sample regions, summarize payment systems and problems of out-patient.
2. Analysis the estimation of global budget, conditions and regulatory mechanism of out-patient of NCMS.Proposed measurement methods and mechanisms which is adapt to the status of Chines NCMS.
3. Through typical case analysis in Nanling County, Anhui Province, predict its out-patient costs in 2010, and compare the differences between estimates and actual results, summarize existing problems and shortcomings in the practical application.
4. According to the results and typical case studies and analysis, put forward suggestions of estimation method and conditions for out-patient of NCMS.
【Methodology】
(a) Date sources
1. Choice of sample area city
The level of economic development and geographical distribution were considerd as selection criteria of samples. The sample ares are implement out-patient more than 1 years (especially has implement golobal budget of out-patient).10 samples areas selected:Zhangjiagang and Jurong City in Jiangsu Province, Nanling and Feixi County in Anhui Province, Lintong District and Xunyi country in Shanxi Province, Xundian and Chengjiang County in Yunnan Province, Nanhui District in Shanghai and Qianjiang District in Chongqing.
2. Data collection methods
Site surveys were in june 2009 in 10 sample areas and march 2011 inNanling County, Anhui Province. Specific data collection methods are questionnaires, secondary data collection, key informant interviews.
(b) Analysis Methods
Analysis methods used in this study are the literature of induction, medical insurance expense premiums method, PETS feasibility analysis, Aanalysis of typical cases.Aanalysis tools are Excel2007 and SPSS11.5.
【Results】
(a) Conclusion
1. Main conclusions of outpatient of samples
1) Problems of NCMS of sample areas
10 sample areas NCMS are at a good stage of development, it is mainly reflect in the following five aspects. First, the participation rate increased every year; Second, the level of funding rate is about 25% annual growth, personal finance accounted in the majority of the sample area per capita net income for the year 0.01%-0.02%; third, NCMS fund balance is stable; Fourth, coverage of hospital and the level of benefit gradually expanded each year; Fifth, at the end of 2008, the family accounts have all been transformed into out-patient co-ordination, co-participation'benifit was extended.
There are also many deficiencies in the operation of NCMS. First, the hospital costs of NCMS grow faster, bring a great risk of NCMS funds; Second, patient co-ordinate fund balances between overruns and large, scientific calculations, cost control and patient supervision of out-patient co-ordinate fund are difficult; third, overall samples are at the start of outpatient co-ordination, the current actual compensation patient are at a low proportion, the attraction on the participation of farmers is not powerful; Fourth, research in individual areas reflect the actual out-patient reimbursement procedures are complex and increase many rural doctors workload.
2) The situation and problem of global budget of out-patient inthe sample areas
At the end of 2009, the 10 sample areas have all been outpatient co-ordination,5 samples regions have global budget of out-patient. Proportion of fund in outpatient co-ordination areas is between 20% -40%, and Nanhui District, Shanghai is at a higher proportion for 43.4% of the total financing of the Fund; Outpatient calculation methods are diversity, but considerations simple in general;The year-end balance sheet flexibility follow the "cost overruns do not fill the balance owned by yourself" principle; addition to the Shanghai Nanhui District covers three-tier health network, the other areas covered by township and village levels;The effect of reducing out-patient medical costs is obvious Nanhui District of Shanghai and Chongqing Qianjiang District.
Problems of global budget of outpatient are as follows:First, outpatient fund is imbalances; Second, the budget estimate methods are simple and lack of scientific basis; Third, year-end balance sheet flexibility are simple; Fourth, information systems in central and western regions is not perfect, bring great difficulties to the out-patient budget estimates, supervision and evaluation.
2 Payment of global budget of out-patient
The design of global budget of outpatient should follow the four principles: feasibility, living within our means to protect the principle of proportionality, protecting the benefit of the supplier, relative stability and change in timely.Proposing the fund of out-patient co-ordinating accounts for annual NCMS fund are between 20%-30%.
The current calculation method are divided into the total cost estimation method, counting method, according to the actual calculation method, calculation method according to the volume of services and calculating method according to the head. The last three measurement methods'basic is still the estimates of health insurance law, just in the estimation of the baseline estimate are in different ways. The estimation of global budget of outpatient of Chinese NCMS summarized are:county-level medical institutions can use the actual calculation method, the township and village-level medical institutions measured by the volume of services. Specific calculation formula is:
Proposed year-end to implement flexible billing to compensate the lack of estimates, Compensation the cost overruns of 60% -75% of to the medical institutions when reasonable overruns as the make up of their health care costs; Balance of 25% -40% will be awarded to medical institutions as a encouragement of its out-patient cost savings. It should be punished for the unreasonable cost overruns and balances.
Supervision and evaluation should be established. The two basic conditions of outpatient global budget are health network covering the construction of information systems and implementation of rural integrated management.
3. The typical case of Nanling County, Anhui Province
Nanling County, Anhui Province meets the basic conditions. According to the calculation of this formula, based on 2009 data, estimates its budget of outpatient of 2010 are 5,383,800 yuan, and increase of coefficient of 1.087, so the total budget adjusted in Nanling County of Anhui Province in 2010 are 5,797,800 yuan.2010 actual expenditure of funds for the outpatient are 5.4697 million yuan, the total budget are more 6.52% than the actual out-fund, which shows that the calculation method is more realistic fund expenditures and have practical significance. The comparison between 2009 and 2010 out-patient data showed that the global budget of out-patient is good at control medical cost, while ensuring the patient fund balance and promoting the use of out-patient services. (B) Discussion
1. Basis of flexible year-end settlement
Flexible year-end settlement of the labor cost calculated is only the income structure of rural doctors a rough analysis, lack of township and county level analysis of the cost structure of medical institutions.
2. Discuss the estimate method of global budget of out-patient It is should be adjusted on the basis of the actual. It could be servel different grade level standards for outpatient expenses when there are great gaps among medical insititutions.
The average actual compensation are better in the fairness theory when there are small gaps in the actual.
3. Relationship between essential drug system and global budget of out-patient
In typical case study, Nanling County of Anhui Province in 2010 implement the global budget of outpatient and the essential drug zero system. From the theoretical analysis, both essential drug zero system and global budget of outpatient can reduce total outpatient costs prepaid, so the effect of control fees of global budget of out-patient need long-term observation.
(C) Recommendation
1. Based on reality is the premise of gobal budget of out-patient in NCMS
Implement global budget of out-patient has based on a high level of hospital compensation.A high-quality leadership and a management team, strengthen policy guidance and communication with the medical institutions are also needed.
2. Information systems is the basis of gobal budget of out-patient in NCMS
Patient information system play an important role in collecting the outpatient costs, statistics, real-time monitoring. It includes computer, network and software facilities, more importantly, the computer operator. Main inputs sourse is finance while social capital is encouraged.
3. Scientific estimates is the key of gobal budget of out-patient in NCMS
An estimate of gobal budget of out-patient is a forward-looking calculation, it has many factors, so it is likely to emerge the difference between actual and estimation. The bases of scientific estimates are data collection and reality.
4. Flexible settlement is adjusting of gobal budget of out-patient in NCMS
Flexible settlement can make up the defect in estimate. It is also can give economic incentives to medical institutions and punish poor medical practices.
5. Supervision and evaluation are indemnification of gobal budget of out-patient in NCMS
Establish a supervision system and teams, supervise medical institutions regularly is the smooth implementation of gobal budget of out-patient in NCMS.
新型农村合作医疗(以下简称“新农合”)实施之初是以大病统筹为主,随着筹资水平和住院补偿水平的提高,门诊家庭账户地区开始向门诊统筹转变。2008年,国务院召开全国新型农村合作医疗工作会议提出政策导向,推行门诊统筹。截止2009年底,全国实施门诊统筹地区己达三分之一。
根据卫生部卫生统计年鉴数据,我国2009年较2003年人均卫生总费用年均增长率为16.09%,人均医疗费用年均增长率为19.49%。从医疗总费用的构成来看,在全国范围内门诊费用通常要占到总医疗费用的65%以上,且比重还有增长的趋势。医疗费用的高速增长已经成为医保面临的严峻形势和挑战,新农合门诊也不例外。随着门诊统筹开展及医疗费用的不断增长和补偿水平的提高,部分地区出现了门诊基金超支风险,尤其在实施门诊统筹之后带来的就医需求的巨大释放给新农合门诊统筹顺利开展带来了巨大的挑战和考验。在一定筹资水平下,适宜的支付方式是控制医疗费用,维持基金平衡的重要手段,因此从控制医疗费用和新农合基金平衡的角度亟需对门诊支付制度展开的研究。
在目前支付方式中,控费效果最好的是总额预付,很多地区已经开始采用这种支付方式,相关部门也在积极提倡。卫生部在《关于落实2010年医改任务做好农村卫生服务有关工作的通知》中提出,在开展门诊统筹的地区,积极开展门诊总额预付等支付方式的改革。从费用控制和政策研究的角度来研究门诊总额预付具有十分重要的现实意义。在现有的总额预付研究中,涉及新农合门诊总额预付的研究有限且深度不够,因此从理论研究方面也具有十分重要的意义。
本研究结合实际调查的结果,探讨在现有筹资水平下,如何开展新农合门诊总额预付,为新农合门诊总额预付实施提供参考依据。
二研究目的与内容
(一)研究目的
通过对当前门诊统筹支付方式现状研究,结合总额预付理论分析和实践经验,研究和探讨在农村基层医疗机构实施门诊总额预付的测算办法、实施条件和监管机制,为完善新农合门诊支付制度、促进新农合的可持续发展提供依据。
(二)研究内容
1分析样本地区新农合制度实施情况,重点总结其门诊支付制度现状及存在问题。
2分析新农合门诊现有总额预付的测算方式、实施条件及其运行机制,提出适应我国新农合现状的测算方法和运行机制。
3对安徽省南陵县进行典型案例分析,根据本研究测算方法进行门诊预付总额测算,并在实施一年后分析其实施效果,总结存在的问题并提出相应对策。
4根据现状研究和典型案例研究结果与分析,提出针对新农合门诊总额预付的测算方法和实施条件的建议。
三研究方法
(一)资料来源
1样本地区的选择
根据经济发展水平,兼顾地区分布,选择门诊统筹已经实施1年以上(最好是已经实施门诊总额预付的)的县(市、区)作为研究对象,所选10个样本地区为江苏省张家港市和句容市、安徽省肥西县和南陵县、陕西省临潼区和旬邑县、云南省寻甸县和澄江县、上海市南汇区和重庆市黔江区。
2资料收集方法
本研究在2009年下半年进行一次现场调查,在2011年初收集安徽省南陵县2010年新农合门诊基本数据进行分析。具体资料收集方法主要有问卷调查,二手资料收集,关键知情人访谈。
(二)分析方法
本研究所用的分析方法有文献归纳法,医疗保险费的粗估法,PETS可行性分析法和典型案例研究法；用到的分析工具有Excel2007、SPSS11.5。
四研究结果
(一)主要研究结论
1样本地区门诊统筹现状
(1)样本地区新农合总体状况和存在问题
10个样本地区新农合总体处于良好的发展阶段,主要体现在以下五方面。一是参合率逐年提高；二是筹资水平年增长率在25%左右,多数样本地区个人筹资额占当年农民人均纯收入的0.01%一0.02%之间；三是新农合基金结余总体较稳定；四是住院受益面逐步扩大,受益程度逐年加强；五是截止到2008年,家庭账户已全部转变为门诊统筹,参合群众受益面扩大。
新农合运行中也存在很多不足之处。一是新农合次均住院费用增长速度较快给新农合基金运行带来了极大的风险；二是门诊统筹基金超支和结余情况差异较大,门诊统筹基金科学测算、门诊费用控制和监管难度较大；三是门诊统筹总体处于开始阶段,目前门诊实际补偿比例偏低,对参合农民的吸引力不是很大；四是实际调研中个别地区反映门诊报销手续复杂,给乡村医生增加很多工作量。
(2)样本地区门诊总额预付总体状况和存在问题
截止到2009年,10个样本地区己全部实施门诊统筹,有5个样本地区实施门诊总额预付。己实施门诊统筹地区门诊基金划分比例在20%-40%之间,上海市南汇区划分比例较高,占基金筹资总额的.43.4%；现有门诊总额的测算方法主要是按照服务量测算和按照人头测算两类,两种测算方法存在一定合理性,但总体上考虑因素简单；在年终弹性结算方面,总体遵循“超支不补,结余归己”原则；除上海南汇区覆盖三级卫生网络外,总额预付多覆盖乡村两级医疗机构；上海市南汇区实施总额预付度后,次均门诊费用下降32.14%,降低门诊医疗费用的效果十分明显。
门诊总额预付存在问题为：一是门诊基金收支不平衡；二是门诊总额测算方法简单,考虑因素不足；三是年终弹性结算方法有待完善；四是中西部地区门诊信息系统不健全,给门诊总额预付测算、监督考核都带来了很大困难。
2门诊总额预付支付方式探讨
门诊总额预付方案的设计主要应遵循量入为出和保障基本医疗原则、合理补偿供方原则、可行性原则、相对稳定与适时变动四个原则。建议新农合门诊基金分配占年度统筹基金的20%-30%左右。在筹资增加的基础上,逐年提高新农合门诊统筹基金占总基金的比例。
目前总额预付测算方法分为成本测算法、点数法、按实际测算法、按服务量测算法和按人头测算法五种。
根据对医疗保险费的粗估法探讨,结合我国新农合门诊现状,归纳出适合我国新农合门诊的总额预付测算方法,其公式为：
其中：M为门诊预付总额；A为次均门诊费用标准,在次均费用差别较大时,可以根据实际情况,结合医疗机构服务能力和经济发展水平对医疗机构进行费用分层；S(S=门诊利用率p×服务人口数Popu)为门诊服务量预测值,在服务人口一定的情况下,对门诊就诊率较低的医疗机构可以适当放宽,对门诊利用率较高的医疗机构适当从严；R为实际补偿比；C为增长系数；F为保险因子;i代表县级医疗机构；j代表乡级医疗机构；k代表村级医疗机构；n为县级医疗机构个数；m为乡级医疗机构个数。
门诊总额的测算是一个前瞻性的预测,其实际值受诸多因素影响,为降低不可预测性因素影响,建议年终实施弹性结算。首先确定超支与结余的合理性。对于不合理的超支和结余,应进行一定的处罚。合理超支时,把超支部分的60%-75%补偿给医疗机构,作为对其医疗成本的弥补；结余时,当门诊预付总额结余额≤节省的门诊医疗费用×(25%-40%)时,结余全部归己；当门诊预付总额结余额>节省的门诊医疗费用×(25%-40%)时,其中未超出部分归己。对于不合理的超支和结余要加以惩罚。
监督考核方面建立公示、考核和监督体系,建立考核的指标体系,考核结果与绩效挂钩。实施新农合门诊总额预付两个基本条件是建设覆盖三级卫生网的信息系统和实施乡村一体化管理。
3安徽省门诊总额预付典型案例分析
安徽省南陵县满足实施门诊总额预付的基本条件,根据本论文提出测算公式,以安徽省南陵县2009年数据为基础,测算其2010年基础门诊总额536.35万元,增长系数为1.087,调整后的2010年安徽省南陵县三级医疗机构的门诊预算总额为583.01万元。2010年门诊基金实际支出为546.97万元,总额测算结果仅比实际门诊基金补偿总额多6.52%,由此说明该测算方法比较切合实际基金支出,具有实际应用意义。同时对2009年和2010年门诊数据对比发现,门诊总额预付很好的控制了门诊总费用,控制了门诊医疗费用的过快增长的同时保证门诊基金收支平衡,促进门诊服务的利用,提高了群众受益程度。
(二)讨论
1弹性结算依据
由于数据限制,年终弹性结算中对劳务成本的结算是仅对乡村医生的收入结构进行粗略分析,缺乏对乡级和县级医疗机构的成本结构分析。
2总额测算方法讨论
在对门诊总额进行测算时要结合实际相应调整。在存在乡级医疗机构水平差异较大情况下,可根据实际情况,制定不同等级水平的次均门诊费用标准。在实际测算时,对于乡级和村级医疗机构,也可以采用平均实际补偿比来测算,从理论上更体现公平性。
3基本药物制度与总额预付的关系
在典型案例研究中,安徽省南陵县2010年实施了门诊总额预付,同时也实施了基本药物制度零差价制度。从理论方面分析,基本药物零差价和门诊总额预付都可以降低门诊费用,因此对于总额预付控费作用还需要长期观察。
(三)建议
1立足现实是新农合门诊总额预付的前提
新农合制度门诊统筹实施要建立在住院补偿水平达到一定程度的基础上,同时有领导重视并具有高素质的新农合管理队伍。同时需要加强政策宣传引导和与医疗机构的沟通。
2信息系统是新农合门诊总额预付的基础
门诊信息系统在门诊费用的收集、统计、即时监管方面起了重要作用。它包括电脑和网络及软件设施,最重要的是电脑操作人员。投入方面建议县级财政为主,鼓励引入社会资本。
3科学测算是新农合门诊总额预付的关键
门诊总额预付是一种前瞻性的预测,影响因素诸多,很容易出现与实际有差距的情况。科学合理的测算门诊总额,一方面要建立在数据信息收集的基础上；另一方面要紧密联系实际。
4弹性结算是新农合门诊总额预付的调节
总额预付的测算是一种前瞻性的测算,弹性结算可以弥补诸多不确定性因素导致的测算不准确的缺陷,给因为服务能力增强而超支的医疗机构一定的成本补偿,对主动控费的医疗机构给予一定的经济激励,对不良医疗行为也给予相应的处罚,是实施门诊总额预付的调剂手段。
5监督考核是新农合门诊总额预付的保障
建立一套系统的监督体系和监督队伍,定期对医疗机构的医疗行为监督考核,是顺利实施门诊总额预付的保障。
【Backgrround】
Since 2003, New Rural Cooperative Medical Scheme (NCMS) has made tre-mendous contributions for Chinese rural health care. At the beginning NCMS mainly aim is "Pooling Funds for Serious Illnesses", with the increase of funding level, the hospital has reached a higher compensation level, most regions already have the ability to pool of out-patient service.
In order to expand the benefit package, NCMS in some areas set up the family account model with the development of NCMS, family account model's drawbacks began to appear, the advantages of pooling of out-patient service is gradually emerg-ing. In 2008, the State Council held a national NCMS work conference, put forword policy guidance, basically denied the family accounts, implemente of outpatient co-ordination. At the end of 2009, the area of outpatient co-ordination has reached one-third in China.
Dependented on the Health Statistics Yearbook data of the Ministry of Health, China's total health expenditure in 2009 compared 2003 with gains of up to 145% in 2003, who received treatment in 2008 compared with 2000 per capita health care costs increased by nearly 71%, the rapid growth of medical costs has become a big challenges for medical insurance system, NCMS is also the same. With increasing of medical expenses and compensation level, some regions have arisen risk of fund cost overruns of out-patient. Although there were small per capita fees of outpa-tient, lower compensation, but it has large quantities. Therefore, from the point of view the NCMS fund balance is also needed a systemic research on the total pre-paid system of out-patient system.
In the current method of payment, the best pament system of controlling expense is global budget, which many regions have begun to apply., but it is has no systematic theoretical research.Ministry of Health, "health care reform in 2010 on the implementation of the tasks of rural health services" put forward "in the proposed areas of co-ordination in carrying outout-patient, carrie out payment reform such as global budegets of out-patient". From the perspective of cost control and policy research to study the global budget of outpatient has great practical significance.
This study combines the actual survey results of the current funding levels, how to launch global budget of out-patient of NCMS, providing reference for NCMS.
【Objectives and Contents】
(a) Objectives
Study the payment of out-patient through analysis current situation, combinated withthe theoretical analysis and practical experience in advance, study and explore the estimation of global budget of out-patient, conditions and regulatory mechanism in primary health care institutions in rural medical institutions, improve the out-patient payment system of NCMS and provide the basis for sustainable development.
(b) Contents
1. Analysis the implementation of NCMS in the sample regions, summarize payment systems and problems of out-patient.
2. Analysis the estimation of global budget, conditions and regulatory mechanism of out-patient of NCMS.Proposed measurement methods and mechanisms which is adapt to the status of Chines NCMS.
3. Through typical case analysis in Nanling County, Anhui Province, predict its out-patient costs in 2010, and compare the differences between estimates and actual results, summarize existing problems and shortcomings in the practical application.
4. According to the results and typical case studies and analysis, put forward suggestions of estimation method and conditions for out-patient of NCMS.
【Methodology】
(a) Date sources
1. Choice of sample area city
The level of economic development and geographical distribution were considerd as selection criteria of samples. The sample ares are implement out-patient more than 1 years (especially has implement golobal budget of out-patient).10 samples areas selected:Zhangjiagang and Jurong City in Jiangsu Province, Nanling and Feixi County in Anhui Province, Lintong District and Xunyi country in Shanxi Province, Xundian and Chengjiang County in Yunnan Province, Nanhui District in Shanghai and Qianjiang District in Chongqing.
2. Data collection methods
Site surveys were in june 2009 in 10 sample areas and march 2011 inNanling County, Anhui Province. Specific data collection methods are questionnaires, secondary data collection, key informant interviews.
(b) Analysis Methods
Analysis methods used in this study are the literature of induction, medical insurance expense premiums method, PETS feasibility analysis, Aanalysis of typical cases.Aanalysis tools are Excel2007 and SPSS11.5.
【Results】
(a) Conclusion
1. Main conclusions of outpatient of samples
1) Problems of NCMS of sample areas
10 sample areas NCMS are at a good stage of development, it is mainly reflect in the following five aspects. First, the participation rate increased every year; Second, the level of funding rate is about 25% annual growth, personal finance accounted in the majority of the sample area per capita net income for the year 0.01%-0.02%; third, NCMS fund balance is stable; Fourth, coverage of hospital and the level of benefit gradually expanded each year; Fifth, at the end of 2008, the family accounts have all been transformed into out-patient co-ordination, co-participation'benifit was extended.
There are also many deficiencies in the operation of NCMS. First, the hospital costs of NCMS grow faster, bring a great risk of NCMS funds; Second, patient co-ordinate fund balances between overruns and large, scientific calculations, cost control and patient supervision of out-patient co-ordinate fund are difficult; third, overall samples are at the start of outpatient co-ordination, the current actual compensation patient are at a low proportion, the attraction on the participation of farmers is not powerful; Fourth, research in individual areas reflect the actual out-patient reimbursement procedures are complex and increase many rural doctors workload.
2) The situation and problem of global budget of out-patient inthe sample areas
At the end of 2009, the 10 sample areas have all been outpatient co-ordination,5 samples regions have global budget of out-patient. Proportion of fund in outpatient co-ordination areas is between 20% -40%, and Nanhui District, Shanghai is at a higher proportion for 43.4% of the total financing of the Fund; Outpatient calculation methods are diversity, but considerations simple in general;The year-end balance sheet flexibility follow the "cost overruns do not fill the balance owned by yourself" principle; addition to the Shanghai Nanhui District covers three-tier health network, the other areas covered by township and village levels;The effect of reducing out-patient medical costs is obvious Nanhui District of Shanghai and Chongqing Qianjiang District.
Problems of global budget of outpatient are as follows:First, outpatient fund is imbalances; Second, the budget estimate methods are simple and lack of scientific basis; Third, year-end balance sheet flexibility are simple; Fourth, information systems in central and western regions is not perfect, bring great difficulties to the out-patient budget estimates, supervision and evaluation.
2 Payment of global budget of out-patient
The design of global budget of outpatient should follow the four principles: feasibility, living within our means to protect the principle of proportionality, protecting the benefit of the supplier, relative stability and change in timely.Proposing the fund of out-patient co-ordinating accounts for annual NCMS fund are between 20%-30%.
The current calculation method are divided into the total cost estimation method, counting method, according to the actual calculation method, calculation method according to the volume of services and calculating method according to the head. The last three measurement methods'basic is still the estimates of health insurance law, just in the estimation of the baseline estimate are in different ways. The estimation of global budget of outpatient of Chinese NCMS summarized are:county-level medical institutions can use the actual calculation method, the township and village-level medical institutions measured by the volume of services. Specific calculation formula is:
Proposed year-end to implement flexible billing to compensate the lack of estimates, Compensation the cost overruns of 60% -75% of to the medical institutions when reasonable overruns as the make up of their health care costs; Balance of 25% -40% will be awarded to medical institutions as a encouragement of its out-patient cost savings. It should be punished for the unreasonable cost overruns and balances.
Supervision and evaluation should be established. The two basic conditions of outpatient global budget are health network covering the construction of information systems and implementation of rural integrated management.
3. The typical case of Nanling County, Anhui Province
Nanling County, Anhui Province meets the basic conditions. According to the calculation of this formula, based on 2009 data, estimates its budget of outpatient of 2010 are 5,383,800 yuan, and increase of coefficient of 1.087, so the total budget adjusted in Nanling County of Anhui Province in 2010 are 5,797,800 yuan.2010 actual expenditure of funds for the outpatient are 5.4697 million yuan, the total budget are more 6.52% than the actual out-fund, which shows that the calculation method is more realistic fund expenditures and have practical significance. The comparison between 2009 and 2010 out-patient data showed that the global budget of out-patient is good at control medical cost, while ensuring the patient fund balance and promoting the use of out-patient services. (B) Discussion
1. Basis of flexible year-end settlement
Flexible year-end settlement of the labor cost calculated is only the income structure of rural doctors a rough analysis, lack of township and county level analysis of the cost structure of medical institutions.
2. Discuss the estimate method of global budget of out-patient It is should be adjusted on the basis of the actual. It could be servel different grade level standards for outpatient expenses when there are great gaps among medical insititutions.
The average actual compensation are better in the fairness theory when there are small gaps in the actual.
3. Relationship between essential drug system and global budget of out-patient
In typical case study, Nanling County of Anhui Province in 2010 implement the global budget of outpatient and the essential drug zero system. From the theoretical analysis, both essential drug zero system and global budget of outpatient can reduce total outpatient costs prepaid, so the effect of control fees of global budget of out-patient need long-term observation.
(C) Recommendation
1. Based on reality is the premise of gobal budget of out-patient in NCMS
Implement global budget of out-patient has based on a high level of hospital compensation.A high-quality leadership and a management team, strengthen policy guidance and communication with the medical institutions are also needed.
2. Information systems is the basis of gobal budget of out-patient in NCMS
Patient information system play an important role in collecting the outpatient costs, statistics, real-time monitoring. It includes computer, network and software facilities, more importantly, the computer operator. Main inputs sourse is finance while social capital is encouraged.
3. Scientific estimates is the key of gobal budget of out-patient in NCMS
An estimate of gobal budget of out-patient is a forward-looking calculation, it has many factors, so it is likely to emerge the difference between actual and estimation. The bases of scientific estimates are data collection and reality.
4. Flexible settlement is adjusting of gobal budget of out-patient in NCMS
Flexible settlement can make up the defect in estimate. It is also can give economic incentives to medical institutions and punish poor medical practices.
5. Supervision and evaluation are indemnification of gobal budget of out-patient in NCMS
Establish a supervision system and teams, supervise medical institutions regularly is the smooth implementation of gobal budget of out-patient in NCMS.
引文
[1]我国新型农村合作医疗制度及其可持续发展研究[M].厦门：厦门大学出版社,2007：113-114.
[2]郝潇,袁兆康,.我国中西部地区新农合门诊统筹实施方案分析[J].中国卫生政策研究,2009,(5).
[3]中华人民共和国卫生部,财政部.关于做好2008年新型农村合作医疗工作的通知[Z].卫农卫发2008年17号.
[4]林枫.门诊也该“统筹”[J].中国社会保障,2008,(7)：73
[5]魏哲铭,胡登兵,邢莉,.新型农村合作医疗门诊统筹制度研究综述[J].理论导刊,2010,(2).
[6]郝模,王志锋,毛瑛,李士雪.卫生政策学[M].北京：人民卫生出版社,2005.
[7]左延莉,.新型农村合作医疗门诊统筹模式与家庭账户模式的比较研究[J].中国卫生经济：2006,12.
[8]卢祖洵.社会医疗保险学[M].北京：人民卫生出版社.2007年版.133页.
[9]关朝红.几种医疗保险结算方式的分析比较[J].中国卫生事业管理,1999(05).
[10]仇雨临,孙树菌.医疗保险[M]一化京：中国人民大学出版社,2001.
[11]程晓明,叶露,陈文.医疗保险学[M].日每：复旦大学出版社,2003：87,02.
[12]李良军.医药费用预测模型及保险因子分析——中国农村健康保险试验项目之科学测算 [J].中国卫生事业管理：1994,05.
[13]陈玉铭,王培英,余澐霎.加拿大医院总额管理制度[J].中国卫生资源,2006(03)：140-141.
[14]陈志兴.合理控制医疗费用过快增长的对策一总额预算制度的研究[J].解放军医院管理杂志,1998(01)：70-72.
[15]费朝珲,易云霓.总额预算制在经济合作与发展组织国家中的运用[J].国外医学(卫生经济分册),1996(01)：12-22.
[16]胡善联.医保费用支付方式比较研究[M].上海：上海科学技术出版社2010.3.119
[17]张掖地区地直城镇职工基本医疗保险费用结算暂行办法[EB/OL].(2006-06-12)[2010-10-15].http://www.zhangye.gov.cn/zysjjsc/zcfg/200 606/2400.html.
[18]冯立中.安徽岳西新农合总额预付让医院担责[N].健康报,2010-01-19.
[19]张广慧,孙承岱.大连市职工医疗保险实行总额预算和按项目结算的实践[J].卫生软科学,1998(02).
[20]中华人民共和国卫生部,财政部.关于做好2008年新型农村合作医疗工作的通知[Z].卫农卫发2008年17号.
[21]卫生部：2010年新农合门诊统筹要覆盖50%统筹地区[J].河北中医,2010,(7).
[1]我国新型农村合作医疗制度及其可持续发展研究[M].厦门：厦门大学出版社,2007：113-114.
[2]郝潇,袁兆康,.我国中西部地区新农合门诊统筹实施方案分析[J].中国卫生政策研究,2009,(5),
[3]中华人民共和国卫生部,财政部.关于做好2008年新型农村合作医疗工作的通知[Z].卫农卫发2008年17号.
[4]卫生部：2010年新农合门诊统筹要覆盖50%统筹地区[J].河北中医,2010,(7).
[5]于广军,杨丽,.门诊统筹是医疗保险的必然要求[J].中国医疗保险,2010,(10).
[6]左延莉,胡善联,刘宝,江芹,.新型农村合作医疗门诊统筹模式与家庭账户模式的比较研究[J].中国卫生经济,2006,(12).
[7]杨泓涛,.大理州新型农村合作医疗两种门诊补偿模式运行效果分析[J].卫生软科学：2006,05.
[8]林枫,.门诊统筹需要多做“减法”[J].中国社会保障,2008,(10).
[9]李瑞锋,.新型农村合作医疗门诊统筹模式分析[J].卫生经济研究,2010,(1).
[10]王雅静,西部地区新型农村合作医疗门诊统筹模式探讨
[11]李华业,.新农合门诊统筹模式SWOT分析和对策[J].现代医院管理,2010,(3).
[12]彭婧,.安徽省新型农村合作医疗门诊统筹制度运行情况分析[J].中国初级卫生保健：2009,07.
[13]王艳明,.甘肃今年将在全省实行新农合门诊统筹[J].农村百事通,2010,(6).
[14]车莲鸿,王俊华.新型农村合作医疗基金分配与使用模式选择[J].中国卫生经济,2006；(10)：38～42
[15]卢祖洵,等.社会医疗保险学[M].北京：人民卫生出版社,2003.100-106.
[16]杨金侠.新型农村合作医疗基金测算方法研究[J].卫生经济研究：2005,09.
[17]罗力,等.论次均医疗费用快速增长、需求释放和医保收支平衡分析[J].中国医院管理,2002,(9)：41-42.
[18]程晓明,等.医疗保险学概论[M].上海：复旦大学出版社,2003.84-86.
[19]信息系统助力门诊统筹[J].中国医疗保险,2010,(10).
[2]郝潇,袁兆康,.我国中西部地区新农合门诊统筹实施方案分析[J].中国卫生政策研究,2009,(5).
[3]中华人民共和国卫生部,财政部.关于做好2008年新型农村合作医疗工作的通知[Z].卫农卫发2008年17号.
[4]林枫.门诊也该“统筹”[J].中国社会保障,2008,(7)：73
[5]魏哲铭,胡登兵,邢莉,.新型农村合作医疗门诊统筹制度研究综述[J].理论导刊,2010,(2).
[6]郝模,王志锋,毛瑛,李士雪.卫生政策学[M].北京：人民卫生出版社,2005.
[7]左延莉,.新型农村合作医疗门诊统筹模式与家庭账户模式的比较研究[J].中国卫生经济：2006,12.
[8]卢祖洵.社会医疗保险学[M].北京：人民卫生出版社.2007年版.133页.
[9]关朝红.几种医疗保险结算方式的分析比较[J].中国卫生事业管理,1999(05).
[10]仇雨临,孙树菌.医疗保险[M]一化京：中国人民大学出版社,2001.
[11]程晓明,叶露,陈文.医疗保险学[M].日每：复旦大学出版社,2003：87,02.
[12]李良军.医药费用预测模型及保险因子分析——中国农村健康保险试验项目之科学测算 [J].中国卫生事业管理：1994,05.
[13]陈玉铭,王培英,余澐霎.加拿大医院总额管理制度[J].中国卫生资源,2006(03)：140-141.
[14]陈志兴.合理控制医疗费用过快增长的对策一总额预算制度的研究[J].解放军医院管理杂志,1998(01)：70-72.
[15]费朝珲,易云霓.总额预算制在经济合作与发展组织国家中的运用[J].国外医学(卫生经济分册),1996(01)：12-22.
[16]胡善联.医保费用支付方式比较研究[M].上海：上海科学技术出版社2010.3.119
[17]张掖地区地直城镇职工基本医疗保险费用结算暂行办法[EB/OL].(2006-06-12)[2010-10-15].http://www.zhangye.gov.cn/zysjjsc/zcfg/200 606/2400.html.
[18]冯立中.安徽岳西新农合总额预付让医院担责[N].健康报,2010-01-19.
[19]张广慧,孙承岱.大连市职工医疗保险实行总额预算和按项目结算的实践[J].卫生软科学,1998(02).
[20]中华人民共和国卫生部,财政部.关于做好2008年新型农村合作医疗工作的通知[Z].卫农卫发2008年17号.
[21]卫生部：2010年新农合门诊统筹要覆盖50%统筹地区[J].河北中医,2010,(7).
[1]我国新型农村合作医疗制度及其可持续发展研究[M].厦门：厦门大学出版社,2007：113-114.
[2]郝潇,袁兆康,.我国中西部地区新农合门诊统筹实施方案分析[J].中国卫生政策研究,2009,(5),
[3]中华人民共和国卫生部,财政部.关于做好2008年新型农村合作医疗工作的通知[Z].卫农卫发2008年17号.
[4]卫生部：2010年新农合门诊统筹要覆盖50%统筹地区[J].河北中医,2010,(7).
[5]于广军,杨丽,.门诊统筹是医疗保险的必然要求[J].中国医疗保险,2010,(10).
[6]左延莉,胡善联,刘宝,江芹,.新型农村合作医疗门诊统筹模式与家庭账户模式的比较研究[J].中国卫生经济,2006,(12).
[7]杨泓涛,.大理州新型农村合作医疗两种门诊补偿模式运行效果分析[J].卫生软科学：2006,05.
[8]林枫,.门诊统筹需要多做“减法”[J].中国社会保障,2008,(10).
[9]李瑞锋,.新型农村合作医疗门诊统筹模式分析[J].卫生经济研究,2010,(1).
[10]王雅静,西部地区新型农村合作医疗门诊统筹模式探讨
[11]李华业,.新农合门诊统筹模式SWOT分析和对策[J].现代医院管理,2010,(3).
[12]彭婧,.安徽省新型农村合作医疗门诊统筹制度运行情况分析[J].中国初级卫生保健：2009,07.
[13]王艳明,.甘肃今年将在全省实行新农合门诊统筹[J].农村百事通,2010,(6).
[14]车莲鸿,王俊华.新型农村合作医疗基金分配与使用模式选择[J].中国卫生经济,2006；(10)：38～42
[15]卢祖洵,等.社会医疗保险学[M].北京：人民卫生出版社,2003.100-106.
[16]杨金侠.新型农村合作医疗基金测算方法研究[J].卫生经济研究：2005,09.
[17]罗力,等.论次均医疗费用快速增长、需求释放和医保收支平衡分析[J].中国医院管理,2002,(9)：41-42.
[18]程晓明,等.医疗保险学概论[M].上海：复旦大学出版社,2003.84-86.
[19]信息系统助力门诊统筹[J].中国医疗保险,2010,(10).