通讯作者: 陈迎春, 1039725514@qq.com

DOI：10.12201/bmr.202212.00003

Financial Vulnerability and Risk Protection of Health Insurance Payments in the Countys Healthcare Alliance: Risk Identification, Empirical Mirroring and Policy Pathways

• 摘要：抗风险能力是紧密型县域医共体高质量可持续发展的关键。识别医保基金流动和风险转移过程中可能损害紧密型县域医共体医保支付预算充足性、支付有效性、结算激励性的风险源，能有效移除紧密型县域医共体医保支付的财务脆弱性。本文首先搭建了紧密型县域医共体医保支付脆弱性形成机制的分析框架，对侵蚀医保支付的预算充足性、支付兼容性、结算激励性多源风险进行风险识别。在系统调研国际上整合型医疗组织以价值和人口基础支付、风险调整、风险走廊、医保支付充足性评价为核心的财务脆弱性风险保护经验的基础上，结合中国紧密型县域医共体医保支付的实际，提出构建以预算充足性风险保护（明确预算范围、预算方法科学、明确预算主体权责边界）、支付兼容性风险保护（激励中性理念下融合价值和人口基础的多层次混合支付）、结算激励性风险保护（明确结余形成和转化路径、风险阈值量化和可选择性、风险分担质量绩效评分挂钩）、医保支付充足性评估等为核心的中国紧密型县域医共体医保支付财务脆弱性的风险保护机制。

  关键词： 市级统筹；紧密型县域医共体；医保支付；财务脆弱性；风险保护; ; ; ; 

   

  Abstract: Risk resilience is the key to high-quality and sustainable development of closely-knit county health care communities. Identifying the risk sources in the process of health insurance fund flow and risk transfer that may undermine the budgetary adequacy, payment effectiveness and settlement incentives of health insurance payments in compact county health care communities can effectively remove the financial vulnerability of health insurance payments in compact county health care communities. This paper first builds an analytical framework for the formation mechanism of health insurance payment vulnerability in tightly-knit county health care communities, and identifies the risks of eroding health insurance payment budget adequacy, payment compatibility and settlement incentives from multiple sources. On the basis of systematic research on the international experience of financial vulnerability risk protection of integrated healthcare organisations based on value and population-based payments, risk adjustment, risk corridors, and evaluation of the adequacy of health insurance payments, and taking into account the actual situation of health insurance payments in Chinas tightly-knit county health care communities, it is proposed to build a framework of budget adequacy risk protection (clarifying the scope of budget, scientific budgeting methods, and clarifying the boundaries of authority and responsibility of budget holders), payment Compatibility risk protection (multi-level hybrid payment that integrates value and population bases under the concept of incentive neutrality), settlement incentive risk protection (clear path of balance formation and transformation, quantified and optional risk thresholds, and risk sharing quality performance score linkage), and health insurance payment adequacy assessment as the core risk protection mechanism of financial vulnerability of health insurance payment in Chinas compact county health care communities.

  Key words: Municipal coordination; Countys healthcare alliance; Health insurance payment; Financial vulnerability; Risk protection

  提交时间：2022-12-12

  版权声明：作者本人独立拥有该论文的版权，预印本系统仅拥有论文的永久保存权利。任何人未经允许不得重复使用。
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• 序号	提交日期	编号	操作
  1	2022-10-08	bmr.202212.00003V1	下载

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