Yu Miao, Huang Zhongmou, Zhang Dan, Yang Yansui, Chien Ching-Wen, Tuo Hongwu
Institute for Hospital Management Tsinghua University Beijing China.
Institute for Hospital Management, Shenzhen International Graduate School Tsinghua University Shenzhen China.
Health Care Sci. 2024 Jul 23;3(4):232-237. doi: 10.1002/hcs2.105. eCollection 2024 Aug.
Some regions in China have already implemented capitation payment or capitation budget management for medical insurance funds. However, there remains a shortage of adequate tools and methodologies to accurately quantify differences in population health risks. Therefore, this paper constructs a health performance assessment model that comprises four steps. The first step is to categorize all participants into health risk groups based on whether they have contracted with a family doctor, their age, sex, and the type of consultation. The second step is to categorize health risk groups based on differences in healthcare resource utilization. The third step is to analyze health performance by examining healthcare resource utilization year over year. The fourth step is to apply the assessment results to assist local finance bureaus and medical insurance bureaus in developing incentive schemes. According to cost weights, the health risk groups are split into six classes: insured residents without health care visits, healthy insured person, slightly ill insured patients, ill insured patients, more seriously disease patients, and severely ill insured patients. We evaluate one compact medical community's health performance by examining changes in the proportion of resource usage group size and expense. From 2019 to 2021, both the proportion of patients with severe and ultra-severe diseases and the proportion of costs in the sample increased, according to changes in resource utilization levels. This result indicates that the population's overall health has not improved and that the compact medical community is still primarily focused on treating diseases, with poor implementation of health maintenance measures and minimal improvement in health performance.
中国一些地区已经对医疗保险基金实施了按人头付费或人头预算管理。然而，仍然缺乏足够的工具和方法来准确量化人群健康风险的差异。因此，本文构建了一个包括四个步骤的健康绩效评估模型。第一步是根据参与者是否签约家庭医生、年龄、性别和就诊类型，将所有参与者分为健康风险组。第二步是根据医疗资源利用的差异对健康风险组进行分类。第三步是通过逐年检查医疗资源利用情况来分析健康绩效。第四步是应用评估结果，协助地方财政局和医保局制定激励方案。根据成本权重，健康风险组分为六类：未就诊参保居民、健康参保人、轻症参保患者、患病参保患者、重病参保患者和重症参保患者。我们通过检查资源使用组规模和费用比例的变化来评估一个紧密型医疗共同体的健康绩效。根据资源利用水平的变化，2019年至2021年，样本中重症和超重症患者的比例以及费用比例均有所增加。这一结果表明，人群的整体健康状况没有改善，紧密型医疗共同体仍主要侧重于疾病治疗，健康维护措施落实不力且健康绩效改善甚微。
