三部委出台医保控费意见 "勒紧钱袋"能否不减医疗质量 The three ministries issued medical opinion control fee "Tighten purse"Can not reduce the quality of medical treatment

　　人力资源和社会保障部、财政部、卫生部近日联合发布《关于开展基本医疗保险付费总额控制的意见》，决定用两年左右的时间，在所有统筹地区范围内开展总额控制工作，以控制医疗费用的过快增长。专家指出，医保控费应以保证医疗质量为前提，总额预算办法可进行分配创新，建立“大预算单位”来鼓励各医疗机构联系协调，优化资源配置。

Human resources and social security/The ministry of finance/The ministry of health have jointly issued[About the development of the basic medical insurance for the opinions of the total amount control],Decided to use two years time,In all as a whole the area within the scope of work in total control,To control the rapid increase of the medical costs.Experts say,Health care costs should be controlled to ensure the quality of medical treatment as the prerequisite,Measures the total budget for distribution innovation,To establish"Big budget unit"To encourage the medical institutions relation coordination,Optimize allocation of resources.

医保基金“吃紧” 吹响控费“号角” Medical insurance fund"tight" Sound control fee"horn"

　　由于近年来我国医保覆盖面扩大，医保费用增长过快问题逐步凸显，一些地方医保基金金额日益“吃紧”。

Due to the medical insurance coverage to expand in China in recent years,The medical insurance cost growth gradually highlight problems too,Some local medical insurance fund amount increasing"tight".

　　中欧国际工商学院卫生管理与政策中心主任蔡江南介绍，在我国三大医疗保障制度中，最主要的城镇职工基本医疗保险分为个人账户和统筹账户，“现在‘吃紧’的主要是统筹账户，个人账户还是有盈余”。

China Europe international business school health management and policy center director tsai jiangnan is introduced,In our country's three big medical security system,The main urban employee basic medical insurance is divided into individual account and as a whole account,"now‘tight’Is the main account as a whole,Individual account or a surplus".

　　在此背景下，三部委联合出台医保总额控制意见，所谓医保付费总额控制，指的是医保经办机构依据历史数据和基金收入状况，确定基金支出总额，同时将指标分解到医保定点医院，在以收定支、收支平衡、略有结余的原则下，“结余留用、超支分担”。

In this context,The three ministries declared total amount control medical opinion,The total amount control for medical insurance,Refers to the medical insurance agency orgnaization is based on historical data and fund income status,Determine the total fund spending,At the same time will index decomposition to designated hospital medical insurance,In order to receive a set/balance/A little under the principle of balance,"Balance continue to employ/Overspend share".

　　复旦大学社保研究中心研究员封进认为，总额控制在国际上被认为可约束以药养医、过度医疗等行为。“以往医院和医保结算费用是后付制，医生主导费用有牟利冲动，是当下过度诊疗的主要原因。”封进指出，医保覆盖后，患者因为能报销，也就会更多地去看病，这些原因都会导致医保费用支出不合理增长，给医保基金带来风险。

Fudan university social security research center researchers seal into thought,Total amount control in the world that can be bound to keep medical medicine/Excessive medical treatment, etc."In the past the hospital and medical insurance settlement fee is paid after the system,The doctor is leading cost profit impulse,Is the main reason for the present excessive diagnosis and treatment."Seal into pointed out that,Health coverage after,Because patients can submit an expense account,Will have more to go to the doctor,These reasons will lead to medical insurance cost is not reasonable growth,The medical insurance fund to risks.

　　“医保基金管理的趋势就是定额管理。”平安集团旗下平安养老保险公司政府业务项目经理吴波认为，按照总额、病种、人头的管控模式结合，能够一定程度缓解医生滥用药物，过度医疗等乱象。例如，按照某地医疗费用平均标准，某医疗机构一名病患住院花费四千元左右，其一年收治一万名病患，住院这项费用的总额控制就是四千万元，超出部分就是医院垫钱支付，不再由医保基金覆盖。

"The trend of the medical insurance fund management is the quota management."Peace group's peace endowment insurance company government business project manager lu, think,According to the total/disease/Head of the control mode combining,To a certain degree of ease the doctor drug abuse,Excessive medical treatment the mess.Such as,According to the medical costs in the average standard,A medical institution a patient in hospital cost four thousand yuan,One years were ten thousand patients,The cost of the hospital total control is forty million yuan,Beyond is part of the money to pay for hospital pad,No longer be covered the medical insurance fund.

医保控费将不以降低医疗质量为前提 Medical insurance control fee will not be to reduce the quality of medical treatment as the prerequisite

　　浙江大学医学院附属第一医院一位呼吸科医生告诉记者，“我多开了哪怕一盒药，医院的电脑系统就会弹出禁止的提示。”该医生表示，目前医保局规定开出的药费不能超过病人看病总额的40%，费用控制较以往有所收紧，而医生担心过于控制药费、诊疗费等对于病人的医疗质量会有影响。

Zhejiang university medical school first affiliated hospital a respiratory medicine doctor told reporters,"I will open the even if a box of medicine,The hospital computer system will popup prohibited tip."The doctor said,At present medical insurance bureau issued regulations of medicine can not more than 40% of the total amount of the patient to see a doctor,Cost control is tightening than ever before,And the doctor worry too control medicine/Fee, etc for the patient's medical quality will affect.

　　专家通过调研发现，由于每家机构一年的医保总额指标是一定的，到年底时上海部分医院就会出现因为超支而不收治重病患者等现象。

Experts through the research found,Because each institution a year total health index is certain,By the end of the year Shanghai part of the hospital will appear for overspending and not treated critically-ill patients to wait for a phenomenon.

　　某地方医保中心工作人员表示，对于医保控费可能产生的消极影响，主管部门也制定了应对措施。根据意见，针对实行总额控制后可能出现的推诿拒收病人、降低服务标准、虚报服务量等行为，主管部门会加强对定点医疗机构医疗行为的监管。该工作人员指出，将次均费用、复诊率、住院率、参保人员负担水平、转诊转院率、手术率、择期手术率、重症病人比例等纳入考核指标体系，就是为了控费同时保障医疗质量。

A local health care center staff said,For medical insurance control fee may produce negative influence,The competent departments have established measures.According to the opinion,According to the total amount control may appear after the shuffle rejection patients/Reduce service standard/Any services, etc,The competent department will strengthen the medical behavior to nod medical establishment of supervision.The officer pointed out,Switch are cost/Return visit rate/Hospital admission rates/Ginseng protect personnel to burden level/Referral rate of hospital/Operation rate/Rate of elective surgical procedures/Severe patients scale into the evaluation indicator system,To control cost at the same time guarantee the quality of medical treatment.

还需创新预算单位优化配置 Still need to innovation budget unit optimization configuration

　　专家建议，总额预算的控制方法还须进行“二次创新”。对于意见中提出的“将总额控制目标细化分解到各级各类定点医疗机构”，专家建议，可以建立更大的预算单位来分摊超支费用。

Expert advice,The control method of the total budget shall be also"Secondary innovation".To put forward Suggestions"The total amount control target refining decomposition at various levels to nod medical establishment",Expert advice,Can build a bigger budget units to share cost overruns.

　　蔡江南表示，可以创新办法，联合各级医院形成大的预算单位，鼓励三级医院联系二级医院、一级医院实现预算总额的协调配置。大预算单位使各家医院协调分配医疗资源，病情比较轻的病患可以协调到基层医院治疗，缓解大医院医保总额控制的压力，进行二次分配。

CAI said the,Can innovation measures,Joint hospitals at all levels in the formation of large budget unit,Encourage tertiary hospital contact secondary hospital/Level 1 hospital to realize the coordination of the total budget allocation.Big budget unit make various hospitals coordinate distribution of medical resources,The illness is lighter patients can coordinate to a primary hospital,Ease the large hospital medical insurance amount control pressure,In secondary distribution.

　　今年8月，国家发展改革委等六部委出台了《关于开展城乡居民大病保险工作的指导意见》，要求把大病医保纳入医保范围。封进指出，基本医保总额控制的结余资金可以帮助推进大病医保制度的建立。一些地方已经在尝试新的模式，如政府部门放开一些权力空间给专业保险公司，政府起到制定规则、实施精算等职能，保险公司作为经办方，起到监督作用，促进市场竞争，提高医保的效率和质量。

August,The national development and reform commission and so on six ministries issued[About urban and rural residents to carry out a serious illness insurance work direction],Need a serious illness medical insurance into the scope of medical insurance.Seal into pointed out that,The basic medical insurance amount control the balance of funds can help promote the establishment of a serious illness medical insurance system.Some places have already trying new model,If the government let go of some power space to professional insurance company,The government have set rules/Implementation of actuarial function,The insurance company as handling party,Play a supervisory role,Promote the market competition,Improve the efficiency and quality of health care.

　　专家指出，医保资金管理不应该办成银行，只有控制资金进出，保证收大于支的“钱袋子”功能，而应形成积极的监管机制，分析实际数据，监控不合理支出，有效配置医疗资源。(记者王涛、王原)

Experts say,Medical insurance fund management should not be bank,Only control capital turnover,Ensure that the greater than cigarettes"Fund sources"function,And should develop a positive supervision mechanism,Analysis of actual data,Monitoring is not reasonable expenditure,Efficient allocation of medical resources.(Reporter wang tao/WangYuan)