医疗保健在澳大利亚(含病例组合).ppt

Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,*,*,Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,*,Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,*,*,澳大利亚的系统是怎么不同？,What makes the Australian System so different?,affordability,分配,rationing,负担能力,affordability,全科医生,The General Medical Practitioner,2,守门人,Gate keeper,卫生系统该基金会（神“阿特拉斯”）,The foundation of our health system,(cf the God“Atlas”),守,门,人Gate Keeper,3,澳大利亚一目了然,Australia at a glance,第六大土地质量,21.5,米人,2.5,的土著,人口密度最低的（,2/km2,）,气候变化，主要是干,50000,岁原住民结算，,从,1788,年的欧洲殖民,高度城市化,6th largest land mass,21.5,m people,2.5%indigenous,lowest population density(2/km,2,),climate varied,mainly dry,50,000 yrs Aboriginal settlement,European colonisation from 1788,highly urbanised,Source:2011 Census,ABS 2102,澳大利亚一目了然,3,Australia at a glance 3,6,Source:2011 Census,ABS 2012,澳大利亚出生时预期寿命在,65,岁,1901,年,-2010,年,Australian Life Expectancy At Birth and at Age 65 1901-2010,7,澳大利亚的人口按年龄和性别,Australian population by Age and Sex,8,Source:ABS,As at June 2011,澳大利亚,-,死亡年龄,Australia Age at Death,9,Source ABS 2012,土著人健康,Indigenous Health,较低的预期寿命比非土著澳大利亚人,Lower life expectancy than non indigenous Australians,较差的自评健康状况,Poorer,self-rated health,在成年期早期和中期的死亡率较高,Higher,mortality rates in early and middle adult period,肾功能衰竭的主要问题,Renal,failure a major,problem,神话土著人民“生活在内陆地区”,Myth that indigenous people“live in the outback”,10,2004-2008,年死亡的年龄分布,Age distribution of Deaths 2004-2008,(NSW,Qld,SA,WA&NT),Source:AIHW,健康问题社会决定因素,Source:AIHW,Social Determinants of Health,13,政策和策略,及干预措施,POLICIES STRATEGIES&INTERVENTIONS,预防和健康促进,Prevention&health promotion,早期干预,Early intervention,治疗和护理,Treatment&care,康复,Rehabilitation,缓和治疗,Palliation,其他政策,Other policies,资源，系统和研究,Resources,systems and research,社,会,SOCIETAL,文化,Culture,富裕,Affluence,社會凝聚力,Social Cohesion,社會包容,Social inclusion,媒體,Media,語,言,Language,健康詞彙,Health vocabulary,环境因素,ENVIRONMENTAL自然 Natural,人造,Man made,地理位置,GEOGRAPHICA,L,LOCATION,偏遠,Remoteness,緯度,Latitude,社会经济,SOCIO-ECONOMIC教育 Education,就业,Employment,收入和財富,Income&wealth,家庭及街坊,Family&neighbourhood,服務,可及性,Access to services,住房,Housing,移民,/難民,身份,Migration/Refugee Status,食,品安全,Food security,社会角色 SOCIAL ROLES,性别,Gender,伴侣,Partner,父母,Parent,照顧者,Carer,朋友,Friend,僱員,Employee,知识，态度和信念 KNOWLEDGE,ATTITUDES AND BELIEFS健康,涵养,Health Literacy,行为,BEHAVIOURAL,抽煙,Tobacco use,喝酒,Alcohol consumption,體力活動,Physical activity,飲食行為,Dietary BehaviourUse of Illicit Drugs,吸毒,性行为,Sexual Practices,疫苗接種,Vaccination,心理因素,PSYCHOLOGICAL FACTORS,压力,Stress創傷 Trauma,虐待,Torture,安全,因素,SAFETY FACTORS,風險,承担,Risk taking,暴力,Violence,職業健康與安全,OH&S,生物医学,BIOMEDICAL,出生體重,Birth weight,體重,Body weight血壓,Blood pressure,血液膽固醇,Blood Cholesterol糖耐量,Glucose Tolerance免疫狀態,Immune Status,健康,幸福的时间推移,HEALTH&WELLBEING OVER TIME平均壽命,Life Expectancy,死,亡率,Mortality,主觀健康,Subjective health,功能性健康,Functional health,疾病,Illness&disease,損傷 Injury,個人的身體和心理素質,INDIVIDUAL PHYSICAL AND PSYCHOLOGICAL QUALITIES,遺傳,天賦,Genetic endowment,產前環境,Prenatal environment,老齡化,Ageing,生命歷程,Life course,代際影響,Intergenerational influences,医疗保健 在 澳大利亚,Healthcare in Australia,州政府管理的公立医院,强大的私人医院系统,医生不是雇员,GP,看门人的角色,医学界的力量,联邦系统,联邦和各州,合作与冲突,国民健康保险,除了有私人医疗保险，而不是取代国民健康保险的选项,Public hospitals administered by the states,Strong private hospital system,Doctors mainly private practitioners,GP gatekeeper role,Strength of medical profession,Federal,system,Commonwealth and states,cooperation&conflict,National,health,insurance,Option to have private health insurance,in addition to,not replacing,the national health insurance,14,隐私权,Privacy,提供者和患者之间的直接沟通,由患者决定其他可以知道的人,有严厉的法律规定,Direct communication between provider and patient,Patient decides who else may know,Strict laws in place,15,初级卫生保健,Primary Health Care,综合医疗实践,社区卫生服务,全科医师的诊所，,居家护理,，,地方政府,HACC,（居家及社区照顾）,M,CH,（孕妇和儿童健康）,社区组织,基层医疗服务合作关系,消费者和自助组织,General practice,Community health services,generalist centres,domiciliary nursing,Local government,HACC(Home&Community Care),M&CH(Maternal&Child Health),Community organisations,Primary care partnerships,Consumer and self-help organisations,16,Australian Institute for Primary Care,17,History,历史,Pre 1970s,Private insurance,Charity centres,GPs(private&charity),Hospitals(charity&private),Limited home care,Institutions,70年代以前,私立保险,慈善中心,全科医生（私人与慈善机构）,医院（慈善机构与私立）,有限的家庭保健,机构,Australian Institute for Primary Care,18,History,历史,1970,s,Universalism,Medibank(later Medicare)for GPs&Hospitals,Community Health Centres,Inquiry into home care and welfare services,70年代,普及化,医疗银行（后来成为,国,民医疗保险），覆盖全科与医院服务,社区卫生中心,探索,家庭,护理,与福利服务,Australian Institute for Primary Care,19,History,历史,1980,s,Deinstitutionalisation,Disability rights,Home&community care,Targeted programs,Integration of community health program,80年代,非机构化服务,残疾权利,家庭与社区服务,目标,项目,整体社区卫生项目,Australian Institute for Primary Care,20,The current system in Victoria,维州当前的体制,Approx 5000 GPs,41 community health centres,59 integrated community health services,Home and community care services,Private practitioners,约5000名全科医生,41家社区卫生中心,59个整体社区卫生服务项目,家庭与社区保健服务,私人行医者,背景,Features,澳大利亚公民对医疗服务普遍具有非常高的信任的因素和方面,有一个隐含的期望，服务将是高质量的,当事故发生时，更大的关注是，确保“不再发生在别人身上”,医疗纠纷诉讼率低,Australian citizens generally have a very high trust factor and regard for health services,There is an implicit expectation that services will be of high quality,When mishaps occur,concern is greater towards ensuring that it“does not happen to someone else”,Low levels of medical malpractice litigation,21,政府和,卫生部门,1,Levels of Government&Health 1,卫生部门在各级别的政府之间的不同的重点,The focus of health provision differs between the levels of Government,可以重叠,C,an overlap,可互补,Can be complementary,不同的州政府之间的司法管辖区可以不同（,=,冲突！）,Can differ between jurisdictions in different States(=conflict!),主要,责任,Principal Responsibility,例证,Example(s),联邦,政府,Federal,政策和资金,Policy and Funding,通过澳大利亚医疗保健协议提供的资金,Funding via Australian Healthcare agreements,国民医疗保险,Medicare,老年保健,Aged care,州级,State,提供个性化的护理或服务的系统,Systems that provide individualized care or services,公立医院系统,Public Hospital System,市,政,级,Local,提供一般性的护理或服务系统,Systems that provide generalized care or services,卫生（垃圾收集）,Sanitation(garbage collection),22,政府,和,卫生部门,2,Levels of Government&Health 2,各级政府之间不同的角色,The relative roles as funder,regulator and provider differ across the levels of government,Level,资助者,Funder,协调控制,Regulator,提供者,Provider,联邦,Federal,领导的作用,Leader,控制主要的税收,是医疗卫生主要资金来源,Major source of funding for all healthcare,Controls most forms of taxation,领导的作用,Leader,制定全国性的政策及影响,Develops national policy national influence,提供一些服务，,联邦政府成为一个“买方”,Some service provision,but Commonwealth tends to be a“purchaser”of care,州级,State,依赖联邦政府的,Dependent upon revenues raised through indirect taxation and grants from Commonwealth based on GST revenue,在限制范围内协调,Regulates within circumscribed areas.,领导的作用,Leader,对服务的提供和协调,Leading role in service provision and coordination of service delivery,市,政,级,Local,的资金从市政征费,Generates funds from rates,and to a lesser extent grants from other levels,在限制范围内协调,Regulates within circumscribed areas.,适应,地方需求,提供服务,Service delivery attuned to local needs,23,卫生系统的资金拨款,Funding for health services,所有澳大利亚公民和居民都享有医疗保健，无论有否支付能力,“国民医疗保险”,资金助通过,征收,1.5,的所得税,一般税收收入,药品受益方案,医院治疗,通过省政府,病例组合,不包括的牙科护理,All Australian citizens and residents are entitled to healthcare regardless of ability to pay,“Medicare”,Funded through,a 1.5%levy on income tax,General taxation revenue,Pharmaceutical Benefit Scheme,Hospital care,Via State Governments,Casemix funding,Dental care not covered,24,“,私立医疗系统,”,The“private,system”,大多数医生行医不是雇员,服务费,;,除了公立医院，还有私立医院不是替代,健康服务提供者的选择,选择使用公立或私立医院,辅助医疗,牙科治疗,保险社区评分,普通价格,不能否认一个人的保险,无法取消其原先存在的情况,Most medical practitioners are not employees,Fee for service,Private Hospitals in addition to public hospitals not an alternative,Choice of health provider,Choice of using either a public or private hospital,Ancillary health,Dental care,Insurance Community Rating,Common price(s),Cannot deny a person insurance,Cannot disqualify pre-existing conditions,25,其他的医疗保健经费来源,Other sources of Healthcare Funding,由各州政府管理,交通意外伤害保险,通过年度车辆登记支付的路局保险费,工伤保险,由用人单位缴纳工资总额的比例的保险费,就业“成本”,用者自付,-“,自己掏口袋”,个人缴费,非常不得人心,Regulated by each State,Transport Accident Insurance,Premiums paid via annual vehicle registration,Workcover,Premiums paid based on a proportion of payroll paid by employers,Employment“on-cost”Out of pocket”,Personal payments,Very unpopular,26,谁埋单？,Who pays?,不同付款方法,不同的风险负担,Each system of funding alters the risks of the burden of ill health,27,四种对医院资助的方法,Four methods of funding hospitals*,Capitation,payment per head of the community served,only practical when a population uses one hospital or hospital system,used in USA(population=employees of company which arranges insurance),a version of this is used in one state in Australia,*,Source:Duckett 2001.The Australian Health Care System,按人头拨款,按所服务社区的“人头”数拨款,只有某人群只使用一家医院或同一医院系统时才可能,美国使用(人群=与保险达成协议的公司的雇员),澳州的一个州使用这种方法,*,资料来源：,Duckett 2001.,澳大利亚的卫生服务系统,28,第二种方法：历史形成法,Historical,Hospitals were charities,community gave money,Governments gave subsidy sometimes,Hospitals were deficit funded,ie government made up the difference between cost and revenue,levels set by history,Each year,funding based on last year plus growth,minus savings,plus inflation,plus one-offs etc,now formalised in contract or Health Service Agreement,between hospital and health department,医院作为慈善机构,社区给钱,有时政府给予“补贴”,对医院实行“赤字”资助,即政府补贴成本与收入的差额,以历史额设定资助标准,每年的拨款基于上年的数据，加上增长，减去节余，加上物价上涨，加上一次性支出等等,现在已经在合同或“卫生服务协议”中正式使用,政府卫生部门和医院之间,29,第三种方法：按天数为标准,3,rd Method:Per Diem,Latin for by the day,Funding based on number of patient days beddays,Often tiered-fee steps down for longer stays,Often used for nursing homes,rehabilitation services,palliative care,Used for private hospitals until recently,拉丁语中是“按天”的意思,按病人住院天数为标准拨款病床日,经常分层次-住院时间越长，每天费用越低,主要用于老年护理院，康复中心，缓解痛苦服务,直到最近才用于私立医院,30,第四种方法：按病例数,4,th Method:Per Case,Payment for the number of patients treated,Hospital carries risk of inefficient treatment,Funder carries risk of higher volumes(USA),Budget is based on number of patients x price per patient,按治疗病人数资助,医院承担治疗效率低的风险,资金支持者承担就诊病人更多的风险(美国),预算根据病人数与每个病人价格的乘积,31,病例组合,Casemix,Funding based on mix of cases,Cases weighted,average patient=1,more complex,higher weight,weighting based on Diagnostic Related Groups-DRGs,Australian version:,ARDRG 10.0,根据“病例的混合”拨款,病例的加权指数,一般病人=1,越复杂的病人，加权指数越高,加权指数根据诊断相关组（,DRGs,）,的标准,澳州版本：,诊断相关组澳大利亚修订版,10.0,32,Inpatient Funding:DRGs,住院服务的资助：诊断相关组,DRGs,661,DRGs in 23 Major Diagnostic Categories(MDCs),eg:,Obstetrics,Nervous System,Episodes clinically similar+similar costs,allows for complications and comorbidities,and different complexity,分为661个诊断相关组，23个主要疾病类别，例如：,产科,神经系统,相似临床病程+相似成本,考虑到并发症和合并症,不同的复杂程度,33,诊断相关组的原则：三个两点原则,DRG Principles:Three Twos,Each Group is:,clinically sensible,similar costs,In total,Groups are:,comprehensive,mutually exclusive,Used as:,management tool,funding tool,每个诊断相关组具有：,临床灵敏性,费用相近,总体上，各诊断相关组具有：,包容性,相互排斥性,诊断相关组可以用于：,管理工具,决定资金支持的工具,34,使用诊断相关组加权的案例,Using DRG weighted cases,Comparing workload of different hospitals or units,In Victoria,the average case(casemix weight equal to 1)is called a WIES,Hospital A treats 43,500 patients,which convert to 40,000 average cases(or WIES)and,Hospital B treats 43,500 cases but they are more complex,and convert to 50,000 WIES,Hospital Bs funding will be 125%of Hospital As funding,比较不同医院或科室的工作量,在维多利亚州，平均病例（在病例组合中权重为1）的称为,WIES,医院,A,治疗了43,500名病人，折算为40,000个平均病例（或,WIES）,医院,B,治疗了43,500名病人，但病情比较复杂，因此折算为50,000个,WIES,对医院,B,的资金支持将是医院,A,的12,5%,35,历史,History,DRGs developed in USA for government funders in 1980s(aged and poor-Medicare and Medicaid),Australia began testing in 1985,in Victoria,All states use DRGs,Private hospitals too,诊断相关组（,DRGs）,是20世纪80年代美国为政府资助计划开发的办法（老年人和穷人-医疗照顾和医疗补助）,澳州于1985年开始在维州试行,现在所有的州均使用,DRGs,标准,私立医院亦开始使用此方法,36,为何改变？,Why Change?,Government carried risk of cost blowouts,Little incentive for hospitals to be efficient,Lack of clarity as to what was being funded,hospital not service,Resource use based on history not current needs,政府承担着费用急剧增加的风险,缺乏提高医院效率的动力,对到底要资助什么不清楚,“医院”而不是“服务”,资源的使用是基于历史而不是现实需要,37,以及缩减预算,And to cut budgets,In Australia,Casemix has generally been used to cut budgets,Works by artificial price setting,ie force price lower,get more service for same dollar,or same service for fewer dollars,在澳州，病例组合,Casemix,已经被广泛,用于缩减预算,通过人为地制订价格,把价格压的比较低,为得到同样的钱要提供很多的服务,或者同样服务收入较少的钱,38,按病例组合资助是如何运作的,How Casemix funding works,Specify types of activity:,inpatient,outpatient,teaching&research,Specify inpatient price and volume,Specify outpatient price and volume,Specify teaching and research outputs&price,确定不同类型的工作,住院病人,门诊病人,教学与科研,确定住院病人的价格和数量,确定门诊病人的价格和数量,确定教学和科研的成果和价格,39,Artist unknown source,www.mind-doesnt matter how many resources you have if you dont know how to use them,的病人的决定,Patients options,无论支付能力,Regardless of ability to pay,根据需要治疗,Treatment according to need,GP,由医疗保险,GP funded by Medicare,由州政府资助的公立医院,Public hospitals funded via state governments,41,基层医疗,Primary Care,42,小学及中学护理,Primary&Secondary Care,43,小学及中学护理,2,Primary&Secondary Care 2,44,受规管回扣（医疗保险,),Medicare scheduled fees,受规管回扣（医疗保险,),Scheduled fee,直接支付,direct payment or,“bulk bill”,可能比原定费收取更多的费用,some,charge more than the scheduled fee,GP,的人次在,2009/2010,年的,79.5,由联邦政府直接支付,79.5%of GP attendances in 2009/2010 were bulk billed,45,Source:Medicare Australia 2102,计划录取到公立医院,Admission to public hospital,46,计划录取到民营医院,Admission to private hospital,47,48,卫生保健提供者,Providers,政府,Government,消费者,Consumers,政策,Policy,规,Regulation,学问,Information,服侍,Service,基金,Funding,基金,Funding,中国呢,China,49,卫生保健提供者,Providers,政府,Government,消费者,Consumers,合规性,Compliance,专业机构,Professional Bodies,医生,Medical,护理,Nursing,专职医疗人员,Allied Health,政策,Policy,规,Regulation,基金,Funding,学问,Information,标准,Standards,考证,Research,审计,Audit,鼓吹,Advocacy,投诉,Complaints,服侍,Service,澳大利,亚,Australia,媒體,Media,媒體,Media,“水平”规例,“,Horizontal”Regulation,50,RACGP-,自我调节,RACGP-Self Regulation,51,52,53,战略规划体系,Strategic Planning Systems,我们的愿景是什么？（冲击）,What is our vision(impact?),我们朝哪发展（使命）,Where are we going?(mission),我们如何到达目的地（战略）,How do we get there?(strategies),行动蓝图是什么（预算）,What is our blueprint for action?(budgets),我们怎么知道是否走对了（控制）,How do we know if we are on track?(control),budget,plan,organise,staff,report,coordinate,direct,evaluate,报告,评估,计划,预算,组织,员工,协调,主导,愿景,:,以病人为中心的护理,The Vision:,Patient-centred care,护理的目的是满足个性化需求的病人,Care is designed to meet the individual needs of the patient,55,愿景,:,以病人为中心的护理,The Vision:,Patient-centred care,护理的目的是满足个性化需求的病人,Care is designed to meet the individual needs of the patient,56,预计的澳大利亚年龄人口,Projected Australian Age Demographic,57,Source:AIHW 2008,老年保健,Aged Care,一般健康服务（全科医生，专科医生，医院等）,居家及社区护理方案（,HACC,）,有监督的独立单元房，特殊的住宿房屋，旅馆，养老院,General health services(GPs,specialists,hospitals,etc),Home and community care programs(HACC),Supervised self-contained units,special accommodation houses,hostels,nursing homes,58,老年保健,Aged Care,老年护理是一个被低估的区域医疗卫生服务,地位低,低下,强体力工作,出现问题时被引起注意,Aged care is an