(声明：刊用《中国新闻周刊》稿件务经书面授权) (statement:reproduced[China news weekly]For the manuscript written authorization)

　　

原标题：大处方的最后期限 Original title:DaChuFang deadline

　　医保总额控制会考虑物价水平的提高，就诊人数的增加等，年初给医疗机构定的预算目标也并非钢板一块，“会有弹性空间”

Medical insurance amount control will consider to raise the level of prices,An increase in the number of people to see a doctor, etc,At the beginning of a medical institution to set the budget goal is not a piece of steel plate,"There will be elastic space"

　　为了避免陷入破产的境地，中国的卫生政策决策者未雨绸缪，决定收紧钱袋子。

In order to avoid falling into bankruptcy situation,China's health policy decision makers save for a rainy day,Decided to tighten fund sources.

　　在北京、上海等地正在试点的总额控制，将作为新医改支付制度改革的重要内容，在未来两年内推向全国。12月4日，人力资源与社会保障部(以下简称人社部)网站发布了《关于开展基本医疗保险付费总额控制的意见》(以下简称《意见》)，这份文件由人社部、财政部、卫生部共同颁布，描绘了未来医改控费的路线图：“结合基金收支预算管理加强总额控制，并以此为基础，结合门诊统筹的开展探索按人头付费，结合住院、门诊大病的保障探索按病种付费”。

In Beijing/Shanghai is the total amount of the pilot control,Will the new medical reform as an important content of the payment system reform,In the next two years to the whole China.On December 4,,Human resources and social security(Hereinafter referred to as people club department)Website released[About the development of the basic medical insurance for the opinions of the total amount control](Hereinafter referred to as[opinion]),The document of the club/The ministry of finance/The ministry of health issued jointly,Represents the future of medical cost control map:"Combined with the fund budget management to strengthen the control of total amount,And, on this basis,With the development of the outpatient service as a whole to explore head pay,In combination/The security of outpatient service a serious illness to explore press disease to pay".

　　“全世界都在搞总额控制”，中国医疗保险研究会副会长熊先军告诉《中国新闻周刊》，医疗资源供应的是有限的，而医疗服务需求几近无限性，二者之间存在着矛盾，“而总额控制以收定支，避免医保基金的滥用导致的破产”。

"In all over the world have total control",Chinese medical insurance research board vice-chairman XiongXianJun tell[China news weekly],Medical resources supply is limited,And medical service needs nearly limitless,There are contradictions between them,"And the total amount control to set branch,To avoid the abuse of the medical insurance fund in bankruptcy".

　　作为人社部下辖的智囊机构，中国医疗保险研究会参与了支付制度改革。熊先军表示，《意见》中的总额控制不同于总额预付，前者不是“一包就死”，而是综合考量了年初预算与各种动态因素。比如会考虑物价水平的提高，就诊人数的增加等，年初给医疗机构定的预算目标并非钢板一块，“有弹性空间”。

As people club department under the think-tank,Chinese medical insurance research involved in the payment system reform.XiongXianJun said,[opinion]Total amount control is different from the total amount in advance,The former is not"A pack of die",But comprehensive consideration at the beginning of the budget and all kinds of dynamic factors.For instance will consider to raise the level of prices,An increase in the number of people to see a doctor, etc,At the beginning of a medical institution to set the budget goal is not a piece of steel plate,"Elastic space".

　

　请来的洋处方 The prescription, please

　　在北上广一线城市中，广州和上海医保费用增长过快的问题较为突出。

In the north wide a line in the city,Guangzhou and Shanghai medical insurance cost growth too fast problems are more prominent.

　　2012年11月，广州市人力资源和社会保障局对外公布，随着医保待遇标准的不断调高以及医疗消费需求的增加，广州市的医保基金支付压力不断增大，其中城镇居民医保基金的缺口今年预计到了1.8亿元。从2002年到2007年，上海医保统筹账户连年收不抵支，5年中，医保基金缺口累计已达20亿元。

In November 2012,Guangzhou human resources and social security bureau announced,Along with the medical insurance treatment standard continuously adjustable high and the increase of medical consumption demand,Guangzhou medical insurance fund pays increasing pressure,The medical insurance for urban residents fund gap this year to 180 million yuan.From 2002 to 2007,Shanghai medical insurance as a whole account in successive years close not to branch,Five years,The medical insurance fund gap accumulated has reached 2 billion yuan.

　　熊先军告诉《中国新闻周刊》，从全国来看，尽管目前医保基金收支整体上还算平衡，但是随着医疗服务需求的扩大，如果不加以控制，未来医保基金存在超支风险，形势如此紧迫，控费政策的出台自然是水到渠成。

XiongXianJun tell[China news weekly],nationally,Although the medical insurance fund balance, on the whole, still calculate balance,But with the growing demand for medical services,If not controlled,The future there medical insurance fund risk overspending,Situation so urgent,Control fee policy appearing nature is follow.

　　正如熊先军所说，总额控制已成为国际趋势。

As XiongXianJun said,Total amount control has become the international trend.

　　2011年，一些北京医疗机构人员曾经到德国考察。一位随行的某医院负责人告诉《中国新闻周刊》，德国也在搞总额控制。

In 2011,,Some Beijing medical services have been to study German.A with a hospital manager told[China news weekly],Germany also engaged in total control.

　　德国的具体做法是，如果执行结果超出了预算， 超出部分将由医院和基金会按不同比例分担，如果实际执行结果低于预算， 医院可以得到差额的40%奖励金。为了更有效地控制费用，德国政府首先在全国750家医院进行总额预算的付费政策试点，试点结果显示：750家医院的平均医疗费降低35%，平均住院天数降低30%。

Germany's particular way is,If the implementation results beyond the budget, Beyond the part of the hospital and foundation according to the different proportion of sharing,If the actual implementation results below budget, The hospital can get 40% of the difference between the bounty.In order to more effectively control costs,The German government first in the nation's 750 total hospital budget payment policy pilot,Pilot results show that:750 the average hospital medical treatment cost reduced by 35%,The average hospitalization days reduced by 30%.

　　采取了总额控制的还有台湾。

Take the total amount control and Taiwan.

　　台湾地区自1998年开始逐步推行医疗费用总额预算支付制度，至2002年7月达到全面的总额支付。时任台湾“中央健康保险局”北区分局经理的陈明哲曾在2011年表示：“如果没有实施总额控制，按照过去的增长趋势，我们推算如今的保费支出会比目前至少高出800亿元新台币(约合178亿元人民币)。”

Taiwan since 1998 gradually carried out the total medical expenses budget payment system,To July 2002 the total amount of the way to pay.The Taiwan"The central health insurance"North branch office manager ChenMingZhe once in 2011 said:"If there is no implementation of total control,According to the past growth trend,We calculate the premium spending now than at least more than $80 billion nt(About 17.8 billion yuan RMB)."

　　其实，为了解决医保基金超支的风险，总额控制也早已进入中国政府的视野。2011年6月初，人社部颁布了《关于进一步推进医疗保险付费方式改革的意见》。该意见提出了推进支付方式改革的任务目标：结合基金收支预算管理加强总额控制，探索总额预付。

In fact,In order to solve the risk of the medical insurance fund overspending,Total amount control also had to enter the Chinese government's field of vision.In early June 2011,People club department issued[On further promoting the reform of medical insurance payment advice].This opinion puts forward some payment reform mission objectives:Combined with the fund budget management to strengthen the control of total amount,Explore amount prepaid.

　　而最近出台的《意见》则进一步明确了总额控制的目标，两年内在所有统筹地区推开。

And the recent[opinion]The further clarify the total amount control goal,Two years as a whole area push in all.

　　如何确定总额？

How to determine the amount?

　　按照《意见》所述，各级医疗机构的总额控制目标是层层确定的。

According to the[opinion]mentioned,Medical institutions at all levels of total amount control goal is to determine the layers.

　　其路径是先确定统筹地区总额控制目标，再分解到各级各类定点医疗机构。这相当于给医疗保险机构出了一道数学题，医保基金的蛋糕就这么大，如何在几十家甚至上百家大医院、小医院之间切分，确定分到每家的蛋糕到底有多大？

The path is to determine the total as a whole the area control target,And decomposition of all types and at all levels to nod medical establishment.This is equivalent to give medical treatment insurance institutions out of a math problem,The medical insurance fund of the cake is so big,How to dozens or even hundreds of large hospital/Small hospital segmentation between,To determine how much each of the cake?

　　目前，正在试点总额控制的北京、上海分蛋糕的方法类似，制定当年总额目标时，参考往年医保基金支付给医院的费用等历史数据。

At present,The pilot is total control of Beijing/Shanghai points cake similar to the way,The total for the goal,Reference to the hospital medical insurance fund in previous years to pay the cost of historical data, etc.

　　《意见》吸取了京沪两地的经验：总额控制目标要以定点医疗机构历史费用数据和医疗保险基金预算为基础，考虑医疗成本上涨以及基金和医疗服务变动等情况，科学测算，合理确定。

[opinion]Learn from the experience of just two:Total amount control objectives to nod medical establishment historical cost data and medical insurance fund budget as the foundation,Considering the rising medical costs and fund and medical service changes, etc,Scientific measurement,Reasonably determine the.

　　熊先军认为，这是一种客观选择。整体而言，医保基金整体收支还处于相对平衡状态，从这个纬度考虑，参考历史数据有其合理性。

XiongXianJun think,This is a kind of objective selection.overall,The overall balance of medical insurance fund is still in a state of relative balance,From this latitude to consider,Reference historical data has its rationality.

　　不过，中国医院协会副秘书长庄一强认为，这种分蛋糕的方法有其不足之处。按照《意见》，是以近三年各定点医疗机构服务提供情况和实际医疗费用发生情况为基础，来制定总额控制目标额度。

but,China hospital association deputy secretary-general chong a strong think,This points cake method has its shortcomings.According to the[opinion],Nearly three years is the designated medical institutions to provide services and actual medical expense as the foundation,To make the total amount control target.

　　庄一强具体解释了不足之处。假设同一地区有A、B两所医院。如果A医院管理严格、医生开大处方、过度医疗的情况比较少，那么说明A医院最近几年控费情况好。而同一地区的B医院大处方、多开药、开贵药、多检查等过度医疗的情况较为突出，说明该医院是一家“坏”医院，如果医保机构根据历史数据来确定总额，那么，胃口已经被撑大的坏医院，在这种情况下反而受益，能够拿着过去的账本得到更大的蛋糕。

Chong a strong specific explains deficiencies.Assume that the same region has A/B two hospitals.If A hospital management strictly/The doctor prescribed DaChuFang/Excessive medical situation is less,It means that A hospital in recent years control fee situation well.And the same area of B DaChuFang hospital/Prescribe more/Open your medicine/Many inspection excessive medical situation more outstanding,Show that the hospital is a"bad"hospital,If health care institutions according to the historical data to determine the total amount,so,Appetite has been maintained big bad hospital,In this case it benefit,Can take the past's get more cake.

　　一些卫生系统的人士认为，上述弊端说明总额控制是一种相对粗放的支付方式。

Some people think that health system,The above drawbacks that total amount control is a relatively extensive payment.

　　在复旦大学医院研究所所长高解春看来，如果医保付费改革的目标仅仅是控费，先实施能在短期内奏效的总额预付就是更稳健的选择，但长期来看，总额预付更易导致医生行为扭曲，比如推诿危重病人，降低医疗服务质量等等。而推行总额预付的上海、河北等地均出现了医疗机构推诿病人的现象。

In fudan university hospital institute director high XieChun looks,If medical insurance pay reform goal is only control fee,To implement can in the short term the total amount of work is the choice of more robust in advance,But in the long term,The total advance are more likely to lead to the doctor behavior distortion,Such as shuffle the critically ill patient,Reduce the medical service quality, etc.And the implementation of the total amount of the advance of Shanghai/Hebei etc all appear the medical institutions shuffle the patient's phenomenon.