不同医保类型患者住院费用和补偿水平的比较分析  

Comparative Analysis of Hospitalization Expenses and Compensation Levels for Patients with Different Types of Medical Insurance

作　　者：王鉴 黄成庆[1] 张云 谭华伟 WANG Jian;HUANG Chengqing;ZHANG Yun;TAN Huawei(Chongqing Health Center for Women and Children,Chongqing 400013,China;不详)

机构地区：[1]重庆市妇幼保健院,重庆400013 [2]重庆市医院成本管理研究中心,重庆400700 [3]华中科技大学同济医学院医药卫生管理学院,湖北武汉430030

出　　处：《卫生经济研究》2023年第10期45-49,共5页

基　　金：重庆市医学科研项目“重庆市妇幼保健机构财务运营及发展对策研究”(2022FY201)。

摘　　要：目的:比较分析紧密型医共体试点县不同医保类型患者住院费用和补偿水平,为完善医保支付机制设计提供数据支撑。方法:提取A县2020—2022年住院患者费用明细数据193418条,进行描述性统计分析和独立样本T检验。结果:居民住院医保基金主要流向医共体内(51.93%),职工住院医保基金主要流向医共体外(65.51%);职工医保患者平均住院费用、日均住院费用分别比居民医保患者高出1552.28元、228.05元,政策内报销比例、实际报销比例高出12.62个和9.96个百分点。结论:建立健全紧密型县域医共体的总额预算分级分类机制和费用审核监督机制,探索建立差异化医保支付机制,促进紧密型县域医共体持续高质量发展。Objective To compare and analyze hospitalization expenses and compensation levels for patients with different types of medical insurance in a pilot county of compact medical community,and to provide data support for improving the design of medical insurance payment mechanisms.Methods Detailed cost data of 193418 inpatients in A county from 2020 to 2022 were collected,and descriptive statistical analysis and independent sample T-tests were used.Results The resident hospitalization medical insurance fund mainly flowed into the medical community(51.93%),while the employee hospitalization medical insurance fund mainly flowed tout of the medical community(65.51%).The average hospitalization expenses and daily hospitalization expenses of patients with employee medical insurance were 1552.28 yuan and 228.05 yuan higher than those of patients with resident medical insurance.The reimbursement ratio with polices and actual reimbursement ratio of patients with employee medical insurance were 12.62%and 9.96%higher than those of patients with resident medical insurance.Conclusion It is necessary to establish the total budget classification mechanism and cost review and supervision mechanism of the compact county-level medical community,explore the establishment of differentiated medical insurance payment mechanism,and promote the sustained and high-quality development of the compact county-level medical community.

关 键 词：紧密型医共体 城乡居民医保 城镇职工医保 住院费用 补偿水平 

分 类 号：R197[医药卫生—卫生事业管理]