沈阳市DRGs付费管理路径探索  

Exploration of DRGs Payment Management in Shenyang Medical Insurance

作　　者：韩春丽[1] 马凝 Han Chunli;Ma Ning(Shenyang Social Medical Insurance Bureau,Shenyang,110031)

机构地区：[1]沈阳市社会医疗保险管理局,沈阳110031

出　　处：《中国医疗保险》2018年第4期47-50,54,共5页China Health Insurance

摘　　要：沈阳市医疗保险按照"先管理、后付费"实施方案,采取分组管理与病案规范同步推进模式,历经基础标准建立与病案质量管理,付费方案制定与结算流程设立等几个重要阶段,经过三年的努力,开启DRGs医保付费管理之路。沈阳医保按诊断相关组预定额付费(DRGs-PPS)特点:付费初期选取9家试点医院,直接全病组付费;采取总额预算下的DRGs-PPS,进行目标性总控;建立协商谈判机制,制定付费权重表;付费方案与结算流程同步制定,监管先行;建立激励约束机制,年末清算进行兜底管理。付费首季,结算流程顺畅,系统运行稳定,审核监管到位,初步达到DRGs付费管理预期目的。Shenyang medical insurance takes group management and medical record standard synchronous propulsion mode,and after three years'eff ort,it opens the way of DRGs medical insurance payment management.DRGs-PPS features:9 pilot hospitals were selected at the early stage of the reform to pay directly to the whole disease group;take the DRGs-PPS under the total budget for total target control;establish negotiation mechanism and formulate a pay weight list;the payment scheme is synchronized with the settlement process and pays attention to the supervision;establish incentive and constraint mechanism and carry out total management at the end of the year liquidation.In the fi rst season,the settlement fl ow is smooth,the system runs steadily,the audit supervision is in place,and the expected goal of DRGs payment management is initially reached.

关 键 词：预定额支付 医疗保险 DRGS 

分 类 号：F840.684[经济管理—保险] C913.7[社会学]