医疗保险DRGs付费试点实践与效果评价  

Practice and Effect Evaluation of Medical Insurance DRGs Pay Pilot

作　　者：焦卫平[1] 张晨[1] 郭娜[1] 黑蕴红[1] 李慧[1] Jiao Weiping Zhang Chen Guo Na Hei Yunhong Li Hui(Xuanwu Hospital Affiliated to Capital Medical University, Beijing 100053, China)

机构地区：[1]首都医科大学宣武医院,北京市100053

出　　处：《中国病案》2016年第12期50-51,69,共3页Chinese Medical Record

摘　　要：北京按病种分组付费(BJ-DRG-pps)试点自2011年11月开始,经过5年六家医院的试点基本保证平稳运行,试点内容包括:医保费用结算流程、病案首页合格率、费用结构调整及最重要的政策推广,基本达到了试点预期的目标。然而,五年的实践工作中,无论从医疗机构还是经办机构方面逐渐暴露出许多深层次问题,本文从医疗机构医保管理的角度出发,尝试通过一些数据和事实的分析,深层剖析北京基本医疗保险DRGs付费试点后在费用和管理方面带来的新挑战和机遇,并对通过优化结算流程提高结算率、价格滞后造成的费用结构失衡、定额标准调整机制不健全及配套政策急需细化问题产生原因提出思考建议。Since Nov, 2011, six pilot hospitals has been smooth operated for 5 years. BJ-DRG-pps pilot include： medical insurancesettlement process, the first page of MR qualification rate, cost structure and the most importantpolicy promotion. These issues basically reached the expected goal of the pilot. However, five years of practical work, whether from medical institutions or agencies gradually exposed many deep-seated problems, this article from the perspective of health management of medical institutions, attempted through the analysis of some data and facts, carried out a deep analysis of the challenges and opportunities of Beijing basic medical insurance paid for DRGs after the pilot in cost and managed the proposed suggestions and reasons of the settlement process optimization to improve settlement rate, cost price lag structure imbalance, caused by the quota adjustment mechanism is not perfect and the supporting policies need refinement of the problem.

关 键 词：诊断相关组(DRGs) 费用结构 医疗保险 付费 

分 类 号：R197.32[医药卫生—卫生事业管理]