基于DRGs基本医保福利包设计与效果评估——以肿瘤类疾病为例  

Studying on the design of basic medical insurance benefits package sampled with tumor diseases based on DRGs and its performance evaluation

作　　者：徐俊秀[1] 高建民[2] 

机构地区：[1]西安交通大学第一附属医院人力资源部 [2]西安交通大学公共政策与管理学院

出　　处：《中国卫生事业管理》2017年第1期25-28,32,共5页Chinese Health Service Management

摘　　要：目的以肿瘤类疾病为例设计新的医保补偿模式,并根据虚拟补偿数据评估新的医保补偿模式的补偿效果。方法以DRGs为基础,采用修正的交互式卡方自动检验方法进行分组,利用绝对值法确定每组的标准费用,以现阶段不同医保的补偿比例为基础,设计补偿方案福利包。结果通过按照设计的福利包补偿比例,对于样本数据进行虚拟补偿后总的补偿额为2.68亿元,医保费用提高的额度为总费用的8.8%,但各个分组的补偿比例均较现阶段医保有较大幅度的提升,经过新方案补偿后患者自付费比例下降的幅度为10%。结论新的医保模式可以有效降低患者的自付费比例特别是对于新农合患者,新的医保补偿模式对于患者治疗结果公平性相对现行的医保模式也有较大程度的缓解。Objective To study the design of basic medical insurance benefits package sampled with tumor diseases based on DRGs, and evaluate its performance. Methods Based on ICD-10 international disease coding, data was grouped by interactive chi- square test method （E -CHAID）. And the standard cost of each group was determined by the absolute value. On the basis of dif- ferent medicare reimbursement rate in this stage, the reasonable benefits package was designed. Results By fitting the virtual com- pensation amounts, the total amount of compensation was 268 million Yuan RMB. The amount of increased medical insurance cost accounted for 8.8% of total cost, in which the compensation proportion of each group was drastically increased. Conclusion The new mode of medical insurance can effectively decrease the proportion of patients＇ self-paid cost, especially for patients in new ru- ral cooperative medial system. It can also improve the equity of medical services.

关 键 词：疾病诊断相关组合(DRGs) 标准住院费用 E-CHAID方法 

分 类 号：R197.32[医药卫生—卫生事业管理]