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在医疗保险中,医疗服务的供需双方有其自身的利益需求和特点,医疗服务的供方即医院占有主导地位。有效控制医疗服务的供给,管住医疗消费的上游源头,对有效地避免医疗保险基金的超支和保障参保人员的基本医疗,有着十分重要的意义。由于医疗保险的缴费比例相对稳定,在资源供给量一定的前提下,从维护公众利益立场出发,兼顾各方面利益,研究适合中国国情的、科学的、合理的、可控的、简便易行的结算办法,是摆在我国医改面前的重要课题。虽然医疗保险基金支付结算办法的设计对医疗服务费用的控制至关重要,但医疗保险机构与医疗服务机构在费用支付结算方面关系的处理又一直是医改的难点。医疗保险服务的费用结算是一个复杂的系统,其具体设计涉及到很多方面,在近年的医改中,许多地区都在这方面做了积极探索。综观探索实践之中推行的各种方式,尽管难以从中寻觅无可指摘的办法,对其优劣得失给予评判也还需要时日,但它们无疑都是适应当地情况的一时之选。当此医改即将推向全国之即,我们将选择一些有其自身特色具有代表性的实施办法与方案设计给予评介,以供各地借鉴参考。同时也会考虑各界读者的推荐或点题,我们将尽可能满足大家在规范解决医疗机构与基金关系方面问题的需要。
In medical insurance, both the supply and demand of medical services have their own interests needs and characteristics, and the provider of medical services, that is, the hospital, occupies the leading position. To effectively control the supply of medical services and to control the upstream sources of medical consumption is of great significance for effectively avoiding the overdraft of the medical insurance fund and guaranteeing the basic medical care for the insured persons. Since the contribution rate of medical insurance is relatively stable, under the premise of certain supply of resources and from the standpoint of safeguarding public interests, taking into account the interests of all parties, it is necessary to study scientific, reasonable, controllable and easy-to-use methods suitable for China’s national conditions Settlement measures, is placed in front of China’s medical reform an important issue. Although the design of payment and settlement methods of medical insurance funds is crucial to the control of medical service expenses, the treatment of the relationship between medical insurance institutions and medical service agencies in payment of fees has been a difficult point of medical reform. The cost of medical insurance services settlement is a complex system, the specific design involves many aspects, in recent years, medical reform, many areas have been actively explored in this regard. Looking at the various ways in which explorations are practiced, though it is difficult to find blatant ways to judge their pros and cons, it will undoubtedly take time to adapt them to the situation on the ground. When this medical reform is about to be launched nationwide, we will select some of the implementation measures and program designs that have their own characteristics and representations for reference. At the same time, we will also consider the recommendations or questions of readers from all walks of life. We will try our best to meet the needs of everyone in regulating the relationship between medical institutions and the fund.