医院医疗保险部门介入高值耗材管理对单病种付费的影响  

The Impact of Management of High-value Consumables by Medical Insurance Department of the Hospital on Single-disease Payment

作　　者：杨敏[1] 李宏玲[1] 

机构地区：[1]新疆阿克苏地区第一人民医院医疗保险办公室,843000

出　　处：《中国医疗管理科学》2014年第3期58-61,共4页Chinese Journal Of Medical Management Sciences

摘　　要：目的介绍了医院医疗保险办公室介入医院高值耗材管理的流程,并结合定额管理和临床路径有效控制单病种住院费用。方法本着"有国产优先使用国产,无国产优先使用价格较低的进口材料"的原则,制定相应的高值耗材准入制度和使用制度,把高值耗材自付比例控制在科学的范围之内,确定合理的分担机制。结果按照所选定的2013年上半年和2014年同期4种同病种单病种结算,其相关费用平均统筹费用均呈下降趋势,且均不超过单病种统筹标准;并且医保介入前、后其4病种药占比和其统筹次均费用比较差异有统计学意义。结论借助临床路径的有效推行,合理管理医用高值耗材,能有效降低单病种住院费用, 减少统筹定额支出, 确保医患保三方的利益。Purpose To introduce the process of management of high-value consumables by medical insurance office of the hospital, and effectively control of single-disease hospitalization expenses combined with the quota management and clinical pathway.Method Based on the principle of “domestic priority and priority of low-prices imported materials”, the access system and use system of corresponding high-value consumables are formulated. The self-pay proportion of high-value consumables is controlled within the scientific scope. The reasonable sharing mechanism is determined.Results According to the single-disease settlement of 4 kinds of diseases selected in the same period in the first half of 2013 and 2014, the relevant expenses and average costs both decline, and they do not exceed the overall standard of a single disease; before and after the involvement of medical insurance, the comparative difference of drug proportion and average expense per time of 4 diseases was statistically significant.Conclusion The effective implementation of clinical pathway and reasonable management of medical high-value consumable can effectively reduce the hospitalization expenses of a single disease, reduce overall quota expenditure, and ensure that the interests of hospital, patient and insurance.

关 键 词：医保 高值耗材 临床路径 单病种付费 

分 类 号：R197.32[医药卫生—卫生事业管理]