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把医疗“任性”关进笼子里

2017-08-24 05:46:46   中国青年网

虽然普通人对此学术色彩浓郁的词汇较感陌生,但它并不是什么新鲜事物。早在20世纪80年代,美国政府为了遏制飞涨的医疗费用、提高卫生资源的利用率,即以法律的形式确定“诊断相关分类为付款基础的定额预付款制”。在此背景下,美国新英格兰医疗中心的护士Karen Zander第一个运用了临床路径。这种方法被证实既可缩短住院天数、节约护理费用,又可以达到预期的治疗效果,遂引起了医学界的重视被推而广之。

对于饱受过度医疗、看病贵之苦的国人,让医生规矩行医、让患者明白看病的临床路径的吸引力是显而易见的。济宁医学院附属医院的故事就颇为典型。

2003年,一名姓吕的患者在该院做急性阑尾炎手术,发现同样的治疗收费却大相径庭,他比另一个患者多花了一半,于是投诉到院里。医院经过核查处理,给患者下了保证:同样的病同样治疗同样收费。此后,医院率先启动了临床路径管理改革,以消除按项目付费下的逐利行为。

据济宁医学院附属医院副院长班博介绍,2003年,该院通过制订临床路径,成本测算,剔除不合理的诊疗项目,优化费用结构,出台了单病种限价方案并实施。实施一年后分析显示,在提升诊疗质量的前提下,病种费用平均降幅约30%。如室间隔缺损、房间隔缺损两个病种,平均每例住院费用由1.7万元降至1万元。

实际上,效果是整体上的。一院如此,一国也如此。国家卫计委医政医管局副局长郭燕红称,实施临床路径以来,全国医院平均住院日由2009年的10.5天下降到2016年的9.4天,年均下降0.22天,缩短10.5%。实施临床路径的医疗机构住院患者医疗费用总体呈现下降趋势,费用结构趋于合理,临床路径组的次均住院费用增长幅度基本上均低于非临床路径组。同时,开展临床路径管理的医疗机构,医疗质量和医疗安全指标控制良好。入径人数和完成人数排前10位病种的死亡率、医院感染率、手术部位感染率等指标均处于较低水平。

不过,临床路径的推广对医院、医生是一个考验。原来有几十种药可开,现在被“优化”为几种;原来可以做的检查,现在则不被允许。这种“自由裁量权”的压缩无疑是痛苦的。另外,临床路径如何及时进行更新以回应技术的进步和实践的发展也是问题。

陈海啸说,台州医院引入临床路径管理之始医生们颇不适应,让各科室报临床路径项目全报疑难杂症。这明显是一种抗议或者误解,因为疑难杂症最不适合临床路径。然而,这不是不可克服的。台州医院是通过凝聚共识、强化培训、充分授权逐渐完成了改革。“要通过激励机制、信息化手段让一线的医生也受益、也感到方便,临床路径才容易被接受、被遵循”。

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