医保按病种定额支付方式研究与应用  

The Research and Application of Fixed Payment by Disease in Medical Insurance

作　　者：付晓丽[1] 杨宁[1] 时松和[1] 王硕 FU Xiao-li;YANG Ning;SHI Songhe(College of Public Health,Zhengzhou University,Zhengzhou,450001,China)

机构地区：[1]郑州大学公共卫生学院,郑州450001 [2]河南省民权县医疗保障局,河南民权476800

出　　处：《中国卫生经济》2020年第6期46-49,共4页Chinese Health Economics

基　　金：2015年度河南省医学科技攻关计划项目(201503015)。

摘　　要：目的:分析医保按病种定额支付的运行效果及作用。方法:采集河南省民权县2016年9月-2019年11月纳入按病种定额支付的45种常见疾病的患者住院相关数据,对实施定额支付前后相关指标进行对比分析。结果:45种疾病县外次均住院费用比县内高8 277.08元(241.46%),与去年同期比较,实施按病种定额支付后,45种疾病总住院人次下降4.26%,外转率下降15.32%,县内实际补偿比上升8.37%,县内住院人次提高19.86%。根据时间序列分析,预测实施按病种定额支付后下一年度外转人次下降36.58%,住院总费用节省1 981.71万元(33.80%),医保基金节约982万元(34.46%)。结论:按病种定额支付可引导居民基层就医,节约医保基金,提升基层医疗服务能力,促进"患者、基金"下沉,促进分级诊疗建设。Objective:To analyze the operation effect and role of fixed payment by diseases.Methods:Data related to hospitaliza⁃tion of patients with 45 common diseases who are included in the fixed payment by diseases in Minquan County from September 2016 to November 2019 are collected,and relevant indicators before and after the fixed payment are compared and analyzed.Re⁃sults:The average hospitalization cost for 45 diseases outside the county is 8277.08 yuan(241.46%)higher than the county.Com⁃pared with the same period last year,the total hospitalization for 45 diseases decreases by 4.26%,the rate of outpatients decreases by 15.32%,the actual compensation ratio in the county increases by 8.37%,and the number of hospitalization in the county increases by 19.86%.According to the time series analysis,it is predicted that the outbound patients will decrease by 36.58%,the total hospital⁃ization cost will be saved by 19.82 million yuan(33.80%),and the medical insurance fund will be saved by 9.82 million yuan(34.46%).Conclusion:The fixed payment by disease may guide patients to seek medical treatment within the county,save medical insurance fund,improve the medical service capacity of county hospitals,promote the sinking of“patients and funds”,and promote the construction of hierarchical diagnosis.

关 键 词：医保基金 按病种定额支付 实际补偿比 分级诊疗 

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]