如何构建既“管用”又“高效”的医保支付机制？

Core Viewpoint - The establishment of an efficient and effective medical insurance payment mechanism is crucial for ensuring high-quality medical services, improving fund utilization efficiency, and promoting sustainable development of the medical insurance system [1][7]. Reform Achievements and Current Challenges - The reform of the medical insurance payment mechanism has been a key focus, with significant achievements made since the establishment of the National Medical Insurance Administration, including the establishment of a composite payment system covering inpatient, outpatient, and chronic disease services [3][4]. - The direction of reform has been clarified, with a framework and important policy tools established, including the implementation of DRG/DIP payment methods [3][4]. - There have been improvements in controlling unreasonable medical cost growth through mechanisms like disease group payment standards and total prepayment, which have encouraged medical institutions to optimize processes and reduce unnecessary hospital stays [4][5]. - The foundation for standardization and information technology has been strengthened, with nationwide implementation of unified disease diagnosis and surgical operation coding [4][5]. - Valuable experiences have been accumulated through the reform process, emphasizing the combination of top-level design and local exploration, pilot programs, and collaborative negotiations among stakeholders [5][6]. Key Elements of the Payment Mechanism - The core essence of an effective medical insurance payment mechanism is to transition from passive reimbursement to strategic purchasing, focusing on value-based healthcare [9][10]. - The mechanism aims to achieve three main goals: sustainable operation of medical insurance funds, enhanced accessibility to medical services, and improved public health levels [9][10]. - The five major aspects of the payment mechanism include emphasizing value-based healthcare, continuous innovation in payment methods, strengthening incentive constraints and risk-sharing, establishing a collaborative and data-driven environment, and promoting systemic reforms [10][11]. Innovation and Collaboration - The establishment of an effective medical insurance payment mechanism requires comprehensive innovation and collaborative efforts, moving beyond merely changing payment tools to fundamentally transforming the healthcare purchasing and management model [15][16]. - The process involves seven fundamental shifts, including moving from passive reimbursement to active purchasing and from focusing on quantity to emphasizing value [15][16][17]. - A unified standardization of information systems and high-quality data centers is essential for driving the payment mechanism, requiring high levels of data analysis and management capabilities [18].