目的: 探讨整合服务导向下慢病健康管理医保按人头付费模式的改革进程、实践特征与实施成效,为政策完善提供参考。方法: 采用政策文本分析、案例研究与比较分析,基于政策文件、文献及课题组调研资料,选取安徽濉溪、天津、健康新加坡（HSG）及美国联邦医疗保险高级初级保健管理（Medicare APCM）四个案例进行比较。结果: 我国慢病医保按人头付费已从门诊慢病拓展至门诊慢特病、普通门诊统筹、医共体总额预算及家庭医生签约等场景,呈现从单一支付工具向协同治理机制演进的趋势。较有效的模式普遍具有支付精细化、服务整合化、健康结果导向及数智赋能特征,通过责任绑定、风险校准与绩效闭环等机制,推动慢病管理从被动诊疗转向主动健康管理,实现费用管理、质量提升与健康改善。结论: 按人头付费不仅是医保支付方式改革的重要工具,更是推动慢病健康管理与整合服务体系建设的制度杠杆。未来应强化医保与卫生健康部门协同,完善风险调整、绩效考核及利益分配机制,加强数字智能技术支撑。
Abstract
Objective: The paper attempts to explore the reform process, practical characteristics, and implementation outcomes of capitation payment models for chronic disease management under an integrated service orientation, and to provide references for policy improvement. Methods: Policy text analysis, case study, and comparative analysis were conducted. Based on policy documents, published literature, and research team survey data, four cases were selected for comparison: Suixi County (Anhui Province, China), Tianjin City (China), Singapore’s Healthier SG, and the US Medicare APCM. Results: Chronic disease capitation payment in China has expanded from outpatient chronic disease coverage to outpatient special/chronic diseases, general outpatient pooling, total budget for county-level medical alliances, and family doctor contracting, showing a trend from a single payment tool toward a collaborative governance mechanism. More effective models generally feature payment refinement, service integration, health outcome orientation, and digital intelligence empowerment. Through mechanisms such as accountability binding, risk calibration, and performance feedback loops, they drive chronic disease management from passive treatment to proactive health management, achieving multiple goals of cost management, quality improvement, and health enhancement. Conclusion: Capitation payment is not only an important tool for medical insurance method payment reform but also a key institutional lever for promoting chronic disease management and integrated service system development. Future efforts should strengthen collaboration between healthcare security administrations and health commissions, improve risk adjustment, performance assessment, and benefit distribution mechanisms, and enhance digital intelligence technology support.
关键词
慢病管理 /
按人头付费 /
医保支付方式 /
整合服务
Key words
chronic disease management /
capitation payment /
medical insurance payment method /
integrated healthcare
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基金
国家自然科学基金面上项目“基于服务效用的整合健康服务价格形成机制与激励策略研究”（72374214）; 国家自然科学基金面上项目“人本导向下整合卫生服务价值测度、评价与共创：基于多维分析框架”（72174207）; 中国健康促进基金会天津市“数字化紧密型医疗卫生健康共同体”实施效果评估科研资助项目
