某社区管理糖尿病患者专病就诊流向与医保费用分布研究  

Study on the distribution of special disease treatment flow and medical insurance cost in diabetics in a community

作　　者：陆萍 朱杰 严海风 高波 戈园园 苏永强 王珏 

机构地区：[1]上海市嘉定区马陆镇社区卫生服务中心全科,上海201801 [2]上海市嘉定区马陆镇社区卫生服务中心行政科,上海201801 [3]上海市嘉定区医疗保险事务中心行政科,上海201800 [4]上海市嘉定区医疗保险事务中心办公室,上海201800

出　　处：《中国卫生资源》2018年第1期71-76,共6页Chinese Health Resources

摘　　要：目的通过分析纳入上海市嘉定区某社区卫生服务中心糖尿病健康管理人群的就诊流向及医保费用分布,了解糖尿病患者的就诊行为和医保费用消耗情况,为分级诊疗政策的推进提出政策建议。方法选取2015年底纳入某社区卫生服务中心糖尿病健康管理的3 280名患者为研究对象,对其在2012—2015年期间的就诊行为及医保费用消耗情况,并对不同医院级别、不同医疗机构的就诊行为及医保费用分布进行对比分析。结果 2012—2015年的4年间,糖尿病患者的总体就诊人数流失率和新增率均在5.00%以内。总体医保费用逐年上升,平均涨幅23.44%。专病就诊人数流失率和新增率基本超过5.00%。专病医保费用逐年上涨,平均增幅21.47%。4年间,糖尿病患者总体就诊和专病就诊主要发生在一级医疗机构,而就诊于二、三级医疗机构的糖尿病患者总体医保费用逐年快速上涨。约80.00%的糖尿病患者就诊于嘉定区某医疗机构,约75.00%的糖尿病患者则是专病就诊于该机构。专病医保费用主要发生于嘉定区某医疗机构(约50.00%)。结论糖尿病专病就诊流失率较高,建立基于信息化的糖尿病社区防治结合是慢性病管理的优化模式。糖尿病患者就诊费用的迅速增长给卫生资源配置带来了巨大的挑战,基于卫生经济学建立最优糖尿病防治模式迫在眉睫。社区卫生服务中心已逐步成为糖尿病诊治及管理的主要机构,建立基于家庭医生制度的慢性病单病种付费模式有利于控制医保费用的过快增长。Objective To understand the medical behaviors of patients with diabetes and the consumption of medical insurance expenses,and put forward policy suggestions to promote the classification and treatment policy by using the analysis of the distribution of and health insurance expenses of the diabetics who had been included in the diabetic health management in a community healthcare center. Methods A total of 3 280 diabetic patients who had been included in the diabetic health management in a community healthcare center at the end of 2015 were selected to study the medical behaviors and the health insurance expenses of diabetics from 2012 to 2015. Then comparative analysis was applied to different ranks of hospitals and various medical institutions. Results From 2012 to 2015,the turnover rate and growth rate of patients with diabetes were within 5.00%. The overall cost of health insurance increased year by year,whose average growth rate was 23.44%. The turnover rate and growth rate of expert clinical visits of diabetics were above 5.00%. The cost of medical insurance for special diseases increased year by year with an average 21.47% growth rate per year. The general and the special clinical visits of diabetics were mainly at the primary medical institutions. However,the overall health insurance expenses of diabetics increased rapidly in secondary or tertiary medical institution. About 80.00% of overall visit of diabetics was in a medical institution of Jiading District with about 75.00% of special clinical visit. The cost of health insurance for special diseases was mainly in a medical institution of Jiading District（about 50.00%）. Conclusion Clinics of experts had a high turnover rate of diabetic patients.Thus,the establishment of information system,which combined prevention and treatment of diabetes in communities,was the optimizing models of chronic disease management.The rapid increase in the cost of diabetes treatment has brought great challenges to the allocation of health resources.It is suggested to estab

关 键 词：糖尿病 就诊流向 医保费用 

分 类 号：R1-9[医药卫生—公共卫生与预防医学] F840.613[经济管理—保险]