目的: 探讨在人口老龄化与慢性病高发背景下,我国康复医保支付政策的现状、问题及优化路径,为提升医保基金使用效能、增强康复服务可及性提供参考。方法: 采用政策文本分析与国际比较方法,系统梳理美国、英国、日本、澳大利亚四国康复医保支付机制在筹资、项目范围、机构协作、支付方式与评估等方面的共同趋势与核心经验;结合我国国家层面政策文件及湖南长沙、江苏南京、广东云浮等试点地区的实践,进行政策演进与模式比较分析。结果: 研究发现,国际康复医保支付改革普遍呈现鼓励商保参与并加强管理、构建场景适配的多元复合支付体系、强化服务连续性及向价值付费转型的共同趋势。我国试点地区在支付方式创新、探索多元筹资、推动医保政策融合等方面已取得积极进展,但仍面临多元支付体系及标准待完善、核心监管指标不统一、评估工具与信息平台待整合等挑战。结论: 健全与服务场景相匹配的多元复合支付体系;完善贯通康复全周期的服务支付链条以促进服务整合,并强化商保支付引导;通过统一评估标准与质控,推动数据标准化与平台建设,引导康复医疗服务高质量发展。
Abstract
Objective: The paper explores the status quo, problems and optimization path of China's rehabilitation medical insurance payment policy in the context of population aging and high incidence of chronic diseases, so as to provide reference for improving the effectiveness of medical insurance fund utilization and enhancing the accessibility of rehabilitation services. Methods: Using policy text analysis and international comparison methods, the study systematically combed the common trends and core experience of the rehabilitation medical insurance payment mechanism in the United States, the United Kingdom, Japan and Australia in terms of financing, project scope, institutional collaboration, payment method and evaluation, etc. Combined with the policy documents at the national level and the practice of pilot regions such as Changsha City of Hunan Province, Nanjing City of Jiangsu Province, and Yunfu City of Guangdong Province, the study carried out a comparative analysis of the evolution of policies and models. Results: The study found that the international rehabilitation medical insurance payment reform generally presents a common trend of encouraging commercial insurance to participate and strengthen management, constructing a multifaceted and composite payment system matching the service scenarios, strengthening the continuity of services, and transforming to value-based payment. China's pilot areas have made positive progress in payment method innovation, multi-source financing, and policy integration, but still face challenges such as incomplete diversified payment systems and standards, inconsistent core regulatory indicators, and unintegrated evaluation tools and information platforms. Conclusions: A multifaceted and composite payment system matching the service scenarios should be improved. The service payment chain through the whole cycle of rehabilitation should be perfected to promote service integration and strengthen the guidance of commercial insurance payment. Data standardization and platform construction should be promoted by unifying evaluation standards and quality control, thus guiding the high-quality development of rehabilitation medical services.
关键词
康复医保支付 /
国际比较 /
地方实践 /
优化策略
Key words
rehabilitation medical insurance payment /
international comparison /
local practice /
optimization strategy
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参考文献
[1] 卫生部,人力资源社会保障部,民政部,等.关于将部分医疗康复项目纳入基本医疗保障范围的通知[J].中华人民共和国国家卫生健康委员会公报,2010(10):6-7.
[2] 陈立典. 康复医学发展与创新[J].科技导报,2023,41(23):1.
[3] 支梦佳,胡琳琳.美国基于功能相关分类法的康复医保支付方式及对我国的启示[J].中国卫生经济,2021,40(07):87-93.
[4] 中华人民共和国中央人民政府.人力资源社会保障部国家卫生计生委民政部财政部中国残联关于新增部分医疗康复项目纳入基本医疗保障支付范围的通知[EB/OL].(2016-03-09)[2025-07-31].https://www.gov.cn/zhengce/zhengceku/2016-04/09/content_5650070.htm.
[5] Centers for Medicare & Medicaid Services. Brief summaries of Medicare & Medicaid, 2020[EB/OL].(2021-11-25)[2025-08-10].https://www.cms.gov/files/document/brief-summaries-medicare-medicaid-november-13-2020.pdf.
[6] 厚生劳动省.关于日本的医疗保险制度[EB/OL].(2017-09-01)[2025-08-12].http://www.mhlw.go.jp/file/06-Seisakujouhou-12400000-Hokenkyoku/0000172084.pdf.
[7] YAMAGUCHI K, NAKANISHI Y, TANGCHAROENSATHIEN V, et al.Rehabilitation services and related health databases[J]. Bulletin of the World Health Organization, 2022,100(11): 699-708.
[8] 闫润楠,颜穆丹,肖丹妮,等.澳大利亚康复医疗服务及医保支付制度的经验与启示[J].中国卫生经济,2023,42(10):92-96.
[9] NHS England. Elective Recovery Fund technical guidance[EB/OL]. (2023-01-27)[2025-08-12].https://www.england.nhs.uk/wp-content/uploads/2023/01/PR00021-elective-recovery-fund-technical-guidance.pdf.
[10] NHS England. NHS standard contract[EB/OL].(2022-10-21)[2025-08-12].https://data.england.nhs.uk/ncdr/data_element/specialised-services-national-definition-set-ssnds/.
[11] 颜穆丹,闫润楠,杨思琪,等.英国康复医疗体系及康复支付制度改革的经验与启示[J].中国康复医学杂志,2023,38(12):1735-1739.
[12] Australian Government Department of Health, Disability and Ageing. Medicare Benefits Schedule (MBS) for chronic disease management[EB/OL].(2004-07-01)[2025-08-11].https://www9.health.gov.au/mbs/fullDisplay.cfm?type=item&qt=ItemID&q=10964.
[13] 安磊,么莉,冯晶晶,等.美国医保支付制度改革对我国康复护理服务的启示[J].中国卫生质量管理,2022,29(04):9-12.
[14] 杜天天,刘跃华,杨燕绥.美国专业护理机构以患者为导向的病例分组支付方式研究——从RUG到PDPM[J].中国卫生政策研究, 2020,13(6):73-80.
[15] 崔志茹,密忠祥,刘菲,等.澳大利亚医疗与康复情况介绍[J].中国医院,2012,16(06):14-16.
[16] 中共中央,国务院.关于深化医疗保障制度改革的意见[EB/OL].(2020-03-05)[2025-07-31].https://www.nhsa.gov.cn/art/2020/3/5/art_37_2808.html.
[17] 国家医疗保障局.关于印发DRG/DIP支付方式改革三年行动计划的通知[EB/OL].(2021-11-26)[2025-08-20].https://www.nhsa.gov.cn/art/2021/11/26/art_104_7413.html.
[18] 关于印发《长沙市康复病组按价值付费医保支付管理办法(试行)》的通知[J].长沙市人民政府公报,2022(04):27-31.
[19] 南京市人民政府.参保价格不变保障待遇再升级 “南京宁惠保”五期正式上线[EB/OL].(2024-09-20)[2025-08-26].ht tps://www.nanjing.gov.cn/msxx/202409/t20240920_5125775.html.
[20] 安庆市医疗保障局.关于印发《安庆市基本医疗保险康复类疾病患者住院按床日付费暂行办法》的通知[EB/OL].(2023-03-31)[2025-07-31].https://ylbzj.anqing.gov.cn/zcwj/zcfg/2002597771.html.
[21] 金华市医疗保障局.金华市卫生健康委员会关于印发金华市基本医疗保险急性后期住院费用付费办法的通知[EB/OL].(2024-09-10)[2025-08-20].http://ybj.jinhua.gov.cn/art/2024/9/10/art_1229154580_1809478.html.
[22] 云浮市医疗保障局.云浮市医疗保障局关于开展康复类病种和严重精神障碍类病种医保支付方式改革的通知[EB/OL].(2024-07-01)[2025-08-20].https://www.yunfu.gov.cn/ybj/zwgk/tzgg/content/post_1830350.html.
