居民医保门诊慢特病支付方式效果系统影响路径研究  

The Research on the Systematic Impact Pathway of Outpatient Chronic and Special Disease Payment Methods in Basic Medical Insurance for Urban and Rural Residents

作　　者：丁一 胡涛[3] 侯晓琨 徐鲁新[5] 宋昱洁 邓又高 丁保扬 孙强 

机构地区：[1]山东大学齐鲁医学院公共卫生学院卫生管理与政策研究中心,济南250012 [2]国家卫生健康委员会卫生经济与政策研究重点实验室(山东大学),济南250012 [3]山东省淄博市医疗保障服务中心,淄博255000 [4]山东省东营市胜利油田中心医院,东营257034 [5]山东省威海市医疗保障服务中心,威海264200

出　　处：《中国医疗保险》2023年第5期97-103,共7页China Health Insurance

摘　　要：目的:探讨居民医保门诊特殊慢性病(以下简称“门诊慢特病”)支付方式效果的系统影响路径,发现支付方式效果的关键影响因素,为健全居民医保门诊慢特病支付机制提供理论依据。方法:成立医保专家小组,使用DEMATEL对专家打分结果进行分析,评价居民医保门诊慢特病支付方式效果相关影响因素的重要程度;利用ISM模型,构建门诊慢特病支付方式效果系统影响路径并发现关键影响因素。结果:DEMATEL分析结果显示,定点医疗机构级别、门诊慢特病实际服务成本、病种数量及准入依据在门诊慢特病支付方式效果中具有较高的中心度,对其他因素影响较大,且不受其他因素影响。ISM模型显示,门诊慢特病支付方式效果的系统影响路径共分为五个层级。门诊慢特病支付方式效果主要由根源层因素即定点医疗机构级别和门诊慢特病的实际服务成本所决定。根源层因素通过长期、直接影响有效深层因素即病种数量及准入依据,并由有效深层因素间接影响其他因素来决定支付方式的最终效果。结论:优化完善门诊慢特病支付方式设计不仅要重点考虑各级定点医疗机构服务能力差异和实际服务成本,更应科学合理地调整病种数量、准入依据和相关配套支付政策。Objective:The paper explores the systematic impact pathways of payment method effect of outpatient special chronic disease system(OSCDS) in Urban and Rural Resident Basic Medical Insurance(URRBMI),and investigates the key influencing factors,which can provide the theoretical basis for optimizing the payment system in outpatient of URRBMI.Method:We set an expert group of medical insurance and analyze the scoring results by DEMATEL to evaluate the importance of each influencing factor.With the ISM model,we establish and discover the systematic impact pathways and key influencing factors of payment method effect.Results:The DEMATLE findings reveal that the level of designed medical institutions,actual service costs,the number and admission criteria have a higher centrality in the payment method of OSCDS,which have a significant impact on other factors and are not affected by other factors.The ISM model shows that the systematic impact pathway of the payment method effect of OSCDS is divided into five levels.The payment method effect of OSCDS is mainly determined by the original factors,namely the level of designated medical institutions and the actual service cost of outpatient chronic and special diseases,the original factors will directly affect the effective underlying factors,i.e.the number of disease types and admission criteria,and effective underlying factors will indirectly influence other indirect influencing factors,thus influencing the efflect of payment method reform.Conclusion:The optimization and improvement of the OSCDS payment methods design should not only focus on the difference in service capacity and actual service costs of designated medical institutions,but also scientifically and rationally adjust the number of disease types,admission criteria and supporting payment policies.

关 键 词：门诊特殊慢性病 支付方式效果 系统影响路径 

分 类 号：F840.684[经济管理—保险] C913.7[社会学]