DIP付费下医院医保收支结余水平影响因素分析——以赤峰市某三甲医院为例  

Analysis of Influencing Factors of Hospitals' Medical Insurance Income and Expenditure Balance Under DIP Payment——Taking a First-class Hospital in Chifeng City as an Example

作　　者：曲建卫 周东波 杜惠峰 咸本松 王文鑫[1] 

机构地区：[1]赤峰市医院,赤峰024000 [2]赤峰市医保局,赤峰024000 [3]内蒙古医科大学卫生管理学院,呼和浩特010110

出　　处：《中国医疗保险》2023年第5期78-83,共6页China Health Insurance

基　　金：内蒙古卫生健康科技计划项目“以DIP付费改革驱动的医院按病种费用控制研究”(202202335);内蒙古自治区自然科学基金项目“基于PSR模型成型居民基本医疗保险基金可持续发展评价研究”(2022MS07001);内蒙古自治区自然科学基金项目“基于利益相关者博弈的公共卫生体系与医疗服务和医疗保障体系融合协同机制研究”(2022LHQN07001)。

摘　　要：目的:本研究拟通过构建医院医保收支水平影响因素模型,为DIP支付方式改革下医院管理医疗费用、控制医疗成本等提供参考依据。方法:收集赤峰市某三级甲等医院2021年11月至2022年6月DIP实际付费病例数据,采用多元线性回归模型分析该院医保收支结余水平的影响因素。结果:本研究共纳入33534例病例,医院医保收支结余水平与患者年龄、医保类型、费用偏差类别、疾病严重程度、手术治疗情况、耗材费用占比、治疗费用占比呈正关联(p<0.001);药品费用占比、病种类型、住院天数与医院医保收支结余水平呈负关联(p<0.001)。结论:DIP付费下,医疗机构应重点控制诊疗成本和药品、耗材费用,管控费用偏差病例,提升医院医保结余水平。医保部门应不断完善DIP付费运行机制,平衡不同医保身份病例的医保支付差异,保障疑难危重病例的医保精准支付,从而正确引导医疗机构加强管理。Objective:This study attempts to construct a model of hospitals' medical insurance revenue and expenditure influencing factors to provide reference for the management of medical expenses and control of medical costs in medical institutions under the DIP payment method reform.Method:We collect data of actual cases paid by DIP from a tertiary hospital in Chifeng City from November 2021 to June 2022,and apply a multiple linear regression model to analyze the influencing factors of the hospital's medical insurance balance level.Results:A total of 33534 cases were included in this study.The hospital's medical insurance revenue and expenditure balance was positively correlated with age,medical insurance type,cost deviation category,disease severity,surgical treatment status,proportion of consumable expenses,and proportion of treatment expenses of patients(p0.001).The proportion of drug expenses,types of diseases,and length of stay are negatively correlated with the hospital's medical insurance balance(p0.001).Conclusion:Under the DIP payment,medical institutions should focus on controlling the cost of diagnosis and treatment as well as drugs and consumables,controlling cases of cost deviation,and improving the hospital's medical insurance balance.The medical insurance department should continuously improve the DIP payment operation mechanism,balance the differences in medical insurance payment for cases with different identities,ensure accurate payment for critically ill cases,and correctly guide medical institutions to strengthen management.

关 键 词：DIP付费 医保收支结余 多元线性回归模型 

分 类 号：F840.684[经济管理—保险]