维持性血液透析门诊费用打包支付的可行性研究——基于福建省某市数据实证分析  

Feasibility Study on Packaging Payment of Outpatient Expenses for Maintenance Hemodialysis--Empirical Analysis Based on Data from a City of Fujian Province

作　　者：康洽福 吴秀芳[2] 洪富源[3] 胡世明 李玉水[4] 

机构地区：[1]中国铁路南昌局集团有限公司福州医疗保险事业管理中心,福州350001 [2]福建中医药大学附属第二人民医院,福州350003 [3]福建省立医院,福州350001 [4]福建江夏学院金融学院,福州350108

出　　处：《中国医疗保险》2023年第10期78-85,共8页China Health Insurance

基　　金：福建省社科研究基地重大项目“保险视角下防范因病致贫返贫风险的长效机制研究”(FJ2022MJDZ040);福建省社会保险人力资源研究会2021年度委托课题“维持性血液透析患者医疗费用影响因素分析与医疗保障政策优化”。

摘　　要：目的:分析维持性血液透析门诊费用影响因素,为开展门诊医保支付方式改革提供参考。方法:基于福建省某市1797名血液透析患者在定点医疗机构的透析费用相关数据,构建多元线性回归模型。结果:影响月均门诊费用的自变量标准化系数由高到低依次为透析次数、是否为独立透析中心、血液透析次数占比、参保人员身份、合并症类别、是否住院、是否终止透析、透析龄,回归模型R2=0.5542,F=241.85,p=0.000;56.52%的透析机构月均门诊费用模型预测数据与实际结算数据相差在±3%范围内。结论:维持性血液透析门诊费用具备医保打包支付条件,建议以签约透析机构为打包支付对象,以月均门诊费用为打包支付单元,结合透析次数形成参数化的医保支付标准。同时,进一步系统化研究按透析质量付费的结算细则、考评体系、激励约束机制。Objective:The paper analyzes the influencing factors of outpatient expenses for maintenance hemodialysis and provides a reference for the reform of outpatient medical insurance payment methods.Methods:Based on the medical cost data of 1797 hemodialysis patients receiving dialysis treatment at designated medical institutions in a city of Fujian Province,a multiple linear regression model was constructed.Results:The standardized coefficients of the independent variables that affect the monthly average outpatient expenses,from high to low,is dialysis frequency,whether it is an independent dialysis center,ratio of hemodialysis frequency to total dialysis frequency,insured person’s identity,category of comorbidity,whether the patients are hospitalized,whether the dialysis terminate,and years of dialysis.The regression model R2=0.5542,F=241.85,p=0.000.56.52%of dialysis institutions have a difference range of±3%between the predicted monthly outpatient cost model data and the actual settlement data.Conclusion:The outpatient expenses for maintenance hemodialysis meet the conditions for medical insurance packaging payment.It is recommended to select designated dialysis institutions as the targets for medical insurance packaging payment,and monthly average outpatient expenses as the unit of packaging payment,and form a parameterized medical insurance payment standard based on the dialysis frequency.At the same time,further systematic research could be conducted on the settlement rules,evaluation system,and incentive-constraint mechanisms for payment based on dialysis quality.

关 键 词：血液透析 门诊费用 影响因素 医保支付方式改革 按病种付费 

分 类 号：F840.684[经济管理—保险] C913.7[社会学]