通讯作者: 张亮

DOI：10.12201/bmr.202306.00005

The Relationship and Mechanism of County Health Insurance Payment and Medical Service Structure Adaptation--Analysis Based on a Typical Case in Yun County

• 摘要：医保与医疗系统协同被视为促进卫生服务体系优化的关键手段，现有研究忽视了两个子系统之间的协同与思考。以云县医共体为研究范本，以适配理论为依据，构建医保支付与医疗服务的跨系统适配分析框架，纵向梳理系统适配路径，揭示适配机理。研究发现，两个子系统间主要有三种适配模式，呈现向下一阶段演进的特征；跨系统适配是一个多因素调节的互动过程，子系统适配地位具有非对等性，呈现“服务优先变革-保障适应调整-服务结构转变-医保引导行为”的全景。本研究对于中国特色医保支付方式适配改革具有一定价值，还有利于形成中国式现代化县域卫生治理的有益经验，推进新时代县域卫生服务高质量发展。

  关键词： 县域；医保支付；医疗服务结构；跨系统适配模型；适配关系; ; ; ; 

   

  Abstract: Synergy between health insurance and medical system is regarded as a key means to promote the optimization of health service system, and existing studies have neglected the synergy and reflection between the two subsystems. Taking Yunxian Medical Community as a research model, we construct a cross-system adaptation analysis framework of health insurance payment and medical services based on adaptation theory, longitudinally sort out the system adaptation paths and reveal the adaptation mechanism. The study finds that there are three main adaptation modes between the two subsystems, which show the characteristics of evolution to the next stage; the cross-system adaptation is a multi-factor adjustment process, and the subsystem adaptation status is non-reciprocal, showing a panorama of service priority change-adaptation of coverage, service structure change-medical insurance guiding behavior. This study is valuable for the reform of health insurance payment method adaptation with Chinese characteristics, and also contributes to the formation of useful experience in modernizing county health governance in Chinese style and promoting high-quality development of county health services in the new era.

  Key words: County; Health insurance payment; Medical service structure; Cross-system adaptation model; Adaptation relationship

  提交时间：2023-06-05

  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	2023-02-22	bmr.202306.00005V1	下载

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