基于大数据的病种分值付费的原理与方法  

Principle And Method Of The Big Data Diagnosis-Intervention Packet(DIP)Payment System

作　　者：许速 谢桦 崔欣 汪森然[3] 应晓华[4] 杨羽佳 应亚珍 Xu Su;Xie Hua;Cui Xin;Wang Senran;Ying Xiaohua;Yang Yujia;Ying Yazhen(Shanghai Municipal Health Commission,Shanghai,200125;Shanghai Information Center for Health,Shanghai,200040;Wonders Information CO.,LTD.,Shanghai,200040;Fudan University,Shanghai,200433;National Institute of Healthcare Security,Capital Medical University,Beijing,100037)

机构地区：[1]上海市卫生健康委员会,上海200125 [2]上海市卫生健康信息中心,上海200040 [3]万达信息股份有限公司,上海200040 [4]复旦大学,上海200433 [5]首都医科大学国家医疗保障研究院,北京100037

出　　处：《中国医疗保险》2020年第9期23-28,共6页China Health Insurance

基　　金：国家医疗保障局委托课题:基于大数据的病种分值付费技术规范研究;上海市卫生健康委员会政策研究课题:推动本市健康大数据开发应用的思路研究(2020HP17)。

摘　　要：基于大数据的病种分值付费是在一般均衡理论的基础上,充分利用我国医疗数据集聚优势及大数据技术创新,形成的以疾病为特征的打包支付方式,能在尽可能少人为干预的前提下,更为精准地拟合成本、测算定价,积极应对国际上医保支付改革的价格发现难题。基于大数据的病种分值付费既拓展了传统按病种分值付费对医疗服务大概率事件的共性特征挖掘模式,又综合考虑了小概率事件的个性特征对医疗服务收入及成本的影响,使价格发现更接近于真实世界的实际状况,更加适应临床的复杂多样,为构建以按病种付费为主的多元复合式医保支付方式提供重要技术支撑。The Big Data Diagnosis-Intervention Packet(DIP)payment system is a packing payment model based on disease characteristics,on the basis of general equilibrium theory,and making full use of the advantages of medical data and innovation of big data technology.DIP payment system can accurately fi t the cost and determine the price with little manual intervention,which can cope with the issues of price discovery in the reform of medical insurance payment.In DIP payment system,not only the mining model of the traditional payment based on the common characteristics of high probability events is expanded,but also the infl uence of the personality characteristics of low probability events on the income and cost of medical services is considered.In this way,the price discovery closer to the actual situation of the real world,can be more suitable for the complexity and diversity of clinical practice,and provides important technical support for the construction of the multi-compound medical insurance payment reform.

关 键 词：大数据 病种分组 监管与支付 方法与原理 

分 类 号：F840.684[经济管理—保险] C913.7[社会学]