DRG改革中负向医疗行为问题及对策综述  

Negative medical behaviors in the context of DRG reform:problems and countermeasures

作　　者：张霄艳[1] 龙俞霖 王卓[1] 胡玉兵 Zhang Xiaoyan;Long Yulin;Wang Zhuo;Hu Yubing(School of Public Administration,Hubei University,Wuhan 430062,Hubei Province,China;Hubei Provincial Bureau of Medical Security)

机构地区：[1]湖北大学公共管理学院,武汉430062 [2]湖北省医疗保障局

出　　处：《中国医疗管理科学》2023年第5期65-70,共6页Chinese Journal Of Medical Management Sciences

基　　金：湖北省教育厅一般项目(21Y012);国家级大学生创新创业训练计划项目(202210512019)。

摘　　要：为限制医保费用的快速增长、缓解患者的就医负担,我国进行了DRG医保支付方式改革,在改革过程中出现了一些负向医疗行为,对患者权益维护、医疗服务质量提升和医保基金监管等带来了负面影响和挑战。通过总结低码高编、医疗服务不足、转移费用、推诿患者这4类常见的负向医疗行为,发现经济利益的驱使、病例组合指数(CMI)考核指标的压力、医保部门监管能力不足是负向医疗行为产生的主要原因,因此,应建立以医疗质量为目的的考核标准,以削弱经济利益动机,引入支付新标准以及多维的考核指标,弥补CMI考核指标的不足,从而完善医保监管机制,顺利推进DRG支付制度改革,避免改革过程中的负向医疗行为。In an attempt to control the rapid growth of health insurance costs and reduce patients'burden associated with medical care,reform of the diagnosis-related group(DRG)-based payment methods has been carried out in China.Unfortunately,negative medical behaviors(NMBs)have occurred during the reform,resulting in negative impacts and challenges on the patients'rights and interests,the quality of health care services,and the supervision of medical insurance funds.An analysis of the four common NMBs including upcoding,insuffcient medical services,cost shifting,and employee shirking revealed that the main causes of these behaviors were undue economic interests,pressure from Level of Service/Case Management Inventory(LS/CMI)-based assessment,and the low monitoring capacity of health insurance authorities.Therefore,it is important to establish medical quality-oriented assessment standards to weaken the economic incentives.Additionally,new payment standards and multi-dimensional assessment indexes should be introduced to make up for the LS/CMI.The health insurance monitoring mechanism should also be optimized to facilitate the DRG payment reform and avoid NMBs during this process.

关 键 词：DRG 负向医疗行为 医药卫生体制改革 

分 类 号：R197[医药卫生—卫生事业管理]