美国DRG付费改革历程对我国医保支付方式改革的启示  

Enlightenment of the DRG payment reform in the United States on the reform of China′s medical insurance payment methods

作　　者：王旖旆 曾雁冰 郜凯华[3] 付卫[4] 金昌晓[1] Wang Yipei;Zeng Yanbing;Gao Kaihua;Fu Wei;Jin Changxiao(Office of Hospital Management Research,Peking University Third Hospital,Beijing 100191,China;School of Public Health,Capital Medical University,Beijing 100069,China;Office of Medical Insurance,Peking University Third Hospital,Beijing 100191,China;Department of General Surgery,Peking University Third Hospital,Beijing 100191,China)

机构地区：[1]北京大学第三医院医院管理研究室,北京100191 [2]首都医科大学公共卫生学院,北京100069 [3]北京大学第三医院医疗保险办公室,北京100191 [4]北京大学第三医院普通外科,北京100191

出　　处：《中华医院管理杂志》2023年第2期93-96,共4页Chinese Journal of Hospital Administration

摘　　要：为解决医疗费用支出增长过快问题,美国于1983年开始进行疾病诊断相关分组(DRG)付费改革,并针对改革过程中暴露出的过度编码与医疗服务质量下降问题制定了系列配套措施。作者介绍了美国实施DRG付费改革的历程,总结了改革引发的医疗机构病例组合的专科化和成本费用降低以及二者之间的关系。提示我国实施医保支付方式改革时,应关注医疗机构过度编码、过度追求效率而忽视质量控制等问题,以及专科化程度加剧导致的综合救治能力及医疗服务质量下降问题。In order to curb the excessive growth of medical expenses,the United States has initiated payment reform of diagnosis-related groups(DRG)since 1983,and developed a series of complementary measures to address issues such as overcoding and declining healthcare service quality which were exposed during the reform.The authors discussed the implementation of DRG payment reform in the United States,namely the case-mix specialization of medical institutions and the reduction of costs,as well as the relationship between the two.On this basis,the authors suggested that when implementing reforms to the medical insurance payment system in China,it is imperative to avoid such loopholes as overcoding by medical institutions and excessive pursuit of efficiency at the expense of quality control,as well as the decline of comprehensive rescue capability and quality of care incurred by the exacerbated specialization.

关 键 词：医疗保障 医疗保险 支付方式改革 疾病诊断相关分组 病例组合专科化 成本 美国 

分 类 号：R197.1[医药卫生—卫生事业管理]