医疗保健在澳大利亚(含病例组合)课件

1、医疗保健 在 澳大利亚Healthcare in AustraliaDecember 5, 2012Xxx 卫生行政大师 Adamm Ferrier RN MHA讲师, 中国卫生项目Lecturer China Health Program卫生科学与人类生物科学学院 School of Public Health & BiosciencesLa Trobe University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

2、General Medical Practitioner3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 Keeper4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% indigenouslowest population

3、 density (2/km2)climate varied, mainly dry50,000 yrs Aboriginal settlement, European colonisation from 1788highly urbanisedSource: 2011 Census, ABS 21026.8m people; 0.8m kms2; 8 Area Health Services4.3m people; 1.7m kms2; 21 Health Service Districts0.2m people; 1.3m kms2; 6 Regions2.15m people; 2.5m

4、 kms2; 4 Area Health Services1.6m people; 0.89m kms2; 4 Health Regions0.4m people; 0.067m kms2; 3 Major Hospitals5.2m people; 0.2m kms2; 8 Regions澳大利亚一目了然 3Australia at a glance 37Source: 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 - 20108澳

5、大利亚 - 死亡年龄Australia Age at Death10Source 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” My

6、th that indigenous people “live in the outback”112004-2008年死亡的年龄分布Age distribution of Deaths 2004-2008(NSW, Qld, SA, WA & NT)Source : AIHW14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O

7、ther 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 GEOGRAPHICAL LOCATION偏遠 Remoteness緯度 Latitude社会经济 SOCIO-ECONOMIC教育 Education就业 Employme

8、nt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

9、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

10、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 envi

11、ronment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 statesStrong private hospital systemDoctors mainly private practitioners GP gate

12、keeper roleStrength of medical professionFederal systemCommonwealth and statescooperation & conflictNational health insuranceOption to have private health insurance in addition to, not replacing the national health insurance15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）MCH（孕妇和

13、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 practiceCommunity health servicesgeneralist centres, domiciliary nursing Local governmentHACC (Home & Community Care)M&CH (Maternal & Child Health)Community organisationsPrimary care partnershipsConsumer and self-help organisations17Australian Institute for Primary

14、 Care18History 历史Pre 1970sPrivate insuranceCharity centresGPs (private & charity)Hospitals (charity & private)Limited home careInstitutions70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 Care19History 历史1970sUniversalismMedibank (later Medicare) for GPs & HospitalsCom

15、munity Health CentresInquiry into home care and welfare services70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 Care20History 历史1980sDeinstitutionalisationDisability rightsHome & community careTargeted programsIntegration of community health program80年代非机构化服务残疾权利家庭

16、与社区服务目标项目整体社区卫生项目Australian Institute for Primary Care21The current system in Victoria维州当前的体制Approx 5000 GPs41 community health centres59 integrated community health servicesHome and community care servicesPrivate 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

17、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 servicesThere is an implicit expectation that services will be of high qualityWhen mishaps occur, concern is greater towards ensuring that it “does not hap

18、pen to someone else”Low levels of medical malpractice litigation22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 governmentLevel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 sourc

19、e of funding for all healthcareControls 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 gra

20、nts 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 circu

21、mscribed areas. 适应地方需求提供服务Service delivery attuned to local needs24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 throu

22、gh a 1.5% levy on income taxGeneral taxation revenuePharmaceutical Benefit SchemeHospital careVia State GovernmentsCasemix fundingDental care not covered25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 eac

23、h StateTransport Accident InsurancePremiums paid via annual vehicle registrationWorkcoverPremiums paid based on a proportion of payroll paid by employersEmployment “on-cost”“Out of pocket”Personal paymentsVery unpopular27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 bur

24、den of ill health28四种对医院资助的方法Four methods of funding hospitals*Capitationpayment per head of the community servedonly practical when a population uses one hospital or hospital systemused in USA (population = employees of company which arranges insurance)a version of this is used in one state in Aust

25、ralia*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29第二种方法：历史形成法HistoricalHospitals were charitiescommunity gave moneyGovernments gave subsidy sometimesHospitals were deficit funded

26、ie government made up the difference between cost and revenuelevels set by historyEach year, funding based on last year plus growth, minus savings, plus inflation, plus one-offs etcnow 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

27、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30第三种方法：按天数为标准3rd Method: Per DiemLatin for by the dayFunding based on number of patient days beddaysOften tiered - fee steps down for longer staysOften used for nursing homes, rehabilitation service

28、s, palliative careUsed 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31第四种方法：按病例数4th Method: Per CasePayment for the number of patients treatedHospital carries risk of inefficient treatmentFunder carries risk of higher volumes (USA)

29、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32病例组合CasemixFunding based on mix of casesCases weighted average patient = 1more complex, higher weightweighting based on Diagnostic Related Groups - DRGsAustralian version:ARDRG 10.0根据“

30、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10.033Inpatient Funding: DRGs住院服务的资助：诊断相关组DRGs661 DRGs in 23 Major Diagnostic Categories (MDCs), eg: ObstetricsNervous SystemEpisodes clinically similar + similar costsallows for complications and comorbiditiesand different compl

31、exity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34诊断相关组的原则：三个两点原则DRG Principles: Three TwosEach Group is:clinically sensiblesimilar costsIn total, Groups are:comprehensivemutually exclusiveUsed as:management toolfunding 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

32、的工具35使用诊断相关组加权的案例Using DRG weighted casesComparing workload of different hospitals or unitsIn Victoria, the average case (casemix weight equal to 1) is called a WIESHospital 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

33、 complex, and convert to 50,000 WIESHospital 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125%36历史 HistoryDRGs developed in USA for government funders in 1980s (age

34、d and poor - Medicare and Medicaid)Australia began testing in 1985, in VictoriaAll states use DRGsPrivate 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37为何改变？ Why Change?Government carried risk of cost blowoutsLittle incentive for hospi

35、tals to be efficientLack of clarity as to what was being fundedhospital not serviceResource 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38以及缩减预算And to cut budgetsIn Australia, Casemix has generally been used to cut budgetsWorks by artificial

36、price settingie force price lowerget more service for same dollaror 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39按病例组合资助是如何运作的How Casemix funding worksSpecify types of activity: inpatientoutpatientteaching & researchSpecify inpatient price and

37、 volume Specify outpatient price and volumeSpecify 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40Artist unknown source /en/quote/242.html 不要紧，你有多少资源，如果你不知道如何使用，然后It doesnt matter how many resources you have if you dont know how to use them的病人的决定Pat

38、ients options无论支付能力Regardless of ability to pay根据需要治疗Treatment according to needGP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 42基层医疗 Primary Care43小学及中学护理Primary & Secondary Care44小学及中学护理2Primary & Secondary Care 245受规管回扣（医疗保险)Medicare scheduled fees受规管回扣（医疗保险)

39、 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 feeGP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 billed46Source: Medicare Australia 2102计划录取到公立医院Admission to public hospital47计划录取到民营医院 Admission to private hospital4849卫生保

40、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China50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A

41、dvocacy投诉Complaints服侍 Service澳大利亚 Australia媒體 Media媒體 Media“水平”规例“Horizontal” Regulation51RACGP - 自我调节RACGP - Self Regulation525354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

42、（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)budgetplanorganisestaffreportcoordinatedirectevaluate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

43、56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 patient57预计的澳大利亚年龄人口Projected Australian Age Demographic58Source: 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, spe

44、cialists, hospitals, etc)Home and community care programs (HACC)Supervised self-contained units, special accommodation houses, hostels, nursing homes59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 undervalued area of health deliveryLow statusLow profile Hard physical workOnly

45、 noticed when it goes wrong60老年护理提供者 Aged Care Providers大多是“非盈利为目的”以宗教或服务为背景政府“购买”服务Most are “not for profit”Religious or service backgroundsGovernment “buys” services61维多利亚州政府的老年护理床Victorian Government Aged Care Beds (2012)62老年护理的资金Funding for Aged Care63低和高护理 Low & High Care64维多利亚州政府的老年护理床Victoria

46、n Government Aged Care Beds65老年保健 Aged Care66财政上的限制Fiscal constraints国家医疗保健协议National Healthcare Agreement做好预防 - 澳大利亚人出生并保持健康基本和社区保健 - 澳大利亚人得到合适的高品质及实惠的基本和社区保健服务医院和相关的护理：澳大利亚人获得合适的高品质，价格合理的医院和医院有关的护理老年护理：澳大利亚老年人得到适当的高品质，负担得起的医疗和老年服务病人的经验：澳大利亚人有很好的保健和老年护理经验，并考虑个别情况及护理需求社会包容性和土著人健康：澳大利亚保健制度促进社会包容性并减少不利性，特别是对澳大利亚土著人可持续发展：澳大利亚人有一个可持续性的医疗保健制度。Prevention Australians are born and remain healthyPrimary and Community Health: Australians receive appropriate high quality and affordable primary and community health servicesHospital and Re