基于大数据的病种分值付费研究:来自上海和广州经验  

The big data diagnosis-intervention packet payment method:experience from Shanghai and Guangzhou

作　　者：许速 邬惊雷 谢桦 林立 曾茜 崔欣 宣建伟 应晓华[5] 杨羽佳 应亚珍 Xu Su;Wu Jinglei;Xie Hua;Lin Li;Zeng Qian;Cui Xin;Xuan Jianwei;Ying Xiaohua;Yang Yujia;Ying Yazhen(Shanghai Municipal Health Commission,Shanghai 200125,China;Shanghai Information Center for Health,Shanghai 200040,China;Guangzhou Municipal Healthcare Security Administration,Guangzhou 510030,China;School of Pharmaceutical Sciences,Sun Yat-Sen University,Guangzhou 510275,China;School of Public Health,Fudan University,Shanghai 200433,China;National Institute of Healthcare Security,Capital Medical University,Beijing 100037,China)

机构地区：[1]上海市卫生健康委员会,200125 [2]上海市卫生健康信息中心,200040 [3]广州市医疗保障局,510030 [4]中山大学药学院,广州510275 [5]复旦大学公共卫生学院,上海200433 [6]首都医科大学国家医疗保障研究院,北京100037

出　　处：《中华医院管理杂志》2021年第3期186-190,共5页Chinese Journal of Hospital Administration

基　　金：国家重点研发计划重点专项(2016YFC1305605);国家自然科学基金(71003024);上海市卫生健康委员会政策研究课题(2020HP17)。

摘　　要：医保支付从按项目的一般购买转向以服务打包为特征的战略型购买,服务包的科学制定是基础,支付标准是核心,过程控制是关键,促使医疗机构以规范化方式贯彻价格标准所指向的标准化诊疗过程,保证支付结果的精准。基于大数据的病种分值付费方法深入贯彻了这一目标,利用统一标准实现了支付与监管的一体化管理,打造了融事前合理预估、事中过程控制、事后评价与资源配置全过程于一体的支付方式,是医疗保障与医疗服务现代化治理的一种符合我国国情的创新型实践。Medical insurance payment model is transforming from project-based purchases to service bundle-based strategic purchases.The new form of bundled purchases should found on a scientifically-led design process of such bundles.The core to bundled purchase would be the payment standard,and the key to its success would be process control.Establishment of such a foundation,a core,and a key,would promote the current price standards,and lead service providers to a standardized medical service standard,so as to ensure a precise rewarding system of payment and service.The big data diagnosis-intervention packet(DIP)is able to fulfill mentioned ambitions by integrating insurance payment and supervision into one management.DIP is a full-process payment mode that encompasses pre-service estimation,in-service process control,post-service grading,and resource allocation.It is an innovative practice in line with China′s national conditions for the modern governance of medical security and medical services.

关 键 词：大数据 病种分值付费 市场机制 预估模型 过程控制 

分 类 号：R197.1[医药卫生—卫生事业管理]