“去年我们节约了5096万元医保资金，全部结余留院。”上海交通大学医学院附属仁济医院医保办主任闻烈告诉记者，“医保总额预付制度实施之后，从医院管理者到普通医生心中都有一根费用控制的弦，在保证医疗质量的基础上有力地遏制了大处方、重复检查。”

"Last year we save 50.96 million yuan medical insurance fund,All balance to leave courtyard."Shanghai jiaotong university school of medicine yan chai hospital subsidiary medical insurance do WenLie director told reporters,"The total advance medical insurance system after implementation,From the hospital managers to the ordinary doctor heart there is a piece of cost control of the string,On the basis of the quality of medical treatment guarantee effectively curb the DaChuFang/Repeated inspection."

　　如今在上海交通大学医学院附属仁济医院，科主任是科室医保费用控制的第一责任人，医院落实了临床路径和单病种质量管理，在骨科、眼科等试点科室推广日间手术，开展同级医院间检查结果互认避免重复检查，严格控制高值耗材和药品支出。“近年来医院的门诊急诊量、住院量每年都有增长，而复诊率保持在低位。”闻烈说，“改革中强调向管理要效益，避免同时带来‘服务不足’等副作用，因此从实施医保总额预付制度的第一天起，就要求不得推诿医保患者，并设立了严格的投诉处罚机制。”

Now in Shanghai jiaotong university school of medicine subsidiary yan chai hospital,Section head is medical insurance cost control department of the first responsible persons,Hospital carried out the clinical path and single disease quality management,In the orthopaedic/Ophthalmology department such as pilot promotion of ambulatory surgery,To carry out the hospital room inspection result recognition to avoid repeated inspection,Strictly control the high value consumables and drug expenditure."In recent years, the hospital outpatient service curves/Hospital quantity every year growth,And return visit rate keep in low."WenLie said,"In the reform of emphasis on economic efficiency and to the management,Avoid at the same time bring‘Insufficient service’Side effects such as,So from the implementation of total medical insurance system in advance of the first day,Requires not shuffle health care patients,And the establishment of a strict punishment mechanism of complaints."

　　上海交通大学医学院附属仁济医院在全院43个临床科室设立了医保专管员，他们既从事医疗等临床工作，又有一定的精算、统计能力，协助实时分析、汇总科室的医保费用支出。泌尿外科主治医师刘毅东就是其中一位医保专管员，3年来，除了合理控制费用外，他还每周与医保办密切联系，及时沟通情况。

Shanghai jiaotong university school of medicine yan chai hospital affiliated institution in 43 clinical departments set up the health care that,They have engaged in medical and clinical work,Also has the certain actuarial/Statistical power,Assist real-time analysis/Summary of the department medical insurance expenses.Urinary surgery resident physician LiuYiDong is one of the special medical insurance,Three years,In addition to the reasonable control of the cost,He also weekly and medical insurance do close contact,Timely communication situation.

　　上海市卫生局医改办主任付晨表示，医保总额预付制度是调动医院积极主动控制医保费用的动力，是当前控制医疗费用不断攀升的有效手段。

Shanghai bureau of health reform, do FuChen director said,The total advance medical insurance system is to mobilize the hospital active power to control the medical insurance cost,Is the current control medical cost rising effective means.

　　截至今年6月，上海全市职工医保参保人数达到1337万余人，居民医保参保人数达到255万余人，加上卫生行政部门管理的新农合参保人员，上海基本实现医保制度全覆盖，户籍人口参保率超过96%。

By June,Shanghai medical insurance ginseng whole city worker to reach more than 13.37 million people,Medical residents contributors reach more than 2.55 million people,The administrative department of public health and the management the new agriculture $ginseng protect personnel,Shanghai basic medical insurance system to realize complete coverage,The household register population participating insurance rate more than 96%.

　　上海市自2002年起实施定点医疗机构医保费用预算管理。2005年起，全市社区卫生服务中心逐步推广开展医保预付试点；2009年对3家三级医院启动医保预付试点；2010年将医保预付范围扩大到10家三级医院和全部公立二级医院；2011年进一步推广到全部三级医院。

Since 2002 the implementation of the medical establishment that decide a dot the medical insurance cost budget management.Since 2005,The city community health service center promotes gradually carry out pilot medical insurance in advance;2009 years to three tertiary hospital medical insurance pilot start in advance;2010 will medical insurance prepaid expanded to 10 tertiary hospitals and all public secondary hospital;2011 years further promotion to all tertiary hospital.

　　“医保盘子”直接关系到医院的利益，也关系到整个基金安全运营合理使用，怎么定才科学？在实施改革过程中，上海通过积极探索医保统筹协调、医院自主协商工作体系，逐步建立起以医保预付为主体的医保总额预算管理模式。

"Medical insurance plate"Directly related to the interests of the hospital,But also related to the whole fund safety operation reasonable use,How to set to science?In the implementation of the reform process,Shanghai through the active exploration medical insurance overall coordination/Hospital independent consultation work system,Step by step build up to medical insurance advance as the main body of the medical insurance total budget management mode.

　　在具体操作中，一是以公开促公平，推进“四个公开”：公开年度基金收支预算和医院预算安排计划；公开全市医院预算指标核定及实际执行情况；公开全市医院预算分配全过程；公开年终清算全部数据。二是以透明促共识，实行“三轮协商”：第一轮由全体医院代表协商；第二轮由三级医院和一二级医院分组协商；第三轮由区内一二级医院协商分配。通过三轮协商，综合考虑不同区域、不同类别、不同级别医院具体因素，确定各医院的预算指标，保证各医院预算指标相对合理均衡。

In the concrete operation of,One is the public to promote fair,propulsion"Four public":Open the annual fund budget and hospital budget plan;Open the city hospital budget index verification and practical implementation;Open the city hospital budget allocation process;Public year-end clearing all the data.The second is transparent to promote consensus,implement"Three-wheel consultation":The first round by all the hospital delegate;The second round of the tertiary hospital and hospital group consultation 12;The third round of the hospital by 12 consultation distribution.Through three rounds consultation,Comprehensive consideration of the different area/Different classes/Different grade hospital specific factors,Determine the hospital budget index,Ensures that each hospital budget index relatively reasonable equilibrium.

　　“上海近年来医保费用年增长幅度大幅下降，医保总额预付制度起到了重要作用。”上海市医疗保险办公室主任郑树忠表示，上海的医保支付方式改革聚焦减少浪费，减轻广大参保人员医疗费用负担，缓解看病贵矛盾；立足多方协同，创新协商谈判，发挥医院自主管理积极性；注重长效机制，确保基金收支平衡，有效地发挥了医保在医改中的基础性作用。(记者仇逸)

"Shanghai in recent years in the medical insurance cost increase sharply,The total advance medical insurance system played an important role."The Shanghai medical insurance office director ZhengShuZhong said,The Shanghai medical insurance payment reform focusing reduce waste,Ginseng protect personnel to reduce the medical expense burden,Ease your contradiction to see a doctor;Based on various cooperative,Innovation talks,Play the hospital independent management enthusiasm;Pay attention to long-term mechanism,Ensure that fund balance,Effectively played in the basic role of the medical insurance reform.(Reporter QiuYi)