按病种分值付费改革下新生儿疾病病种组合优化研究  

Research on the Optimization of Neonatal Disease Combination Under the Reform of DIP Payment

作　　者：蒋丽洁 张红梅[1] 聂川[1] 陈佳[1] 万天宇 欧燕兰[1] 

机构地区：[1]广东省妇幼保健院,广州511400

出　　处：《中国医疗保险》2024年第3期78-82,共5页China Health Insurance

基　　金：广东省卫生经济学会项目“基于临床手术操作价格与病种成本的妇幼专科医院价格管理研究”(2023-WJMZ-59)。

摘　　要：目的:在广州市按病种分值付费病种分值表修订的背景下,分析广州市社会医疗保险按病种分值付费病种分值表(2021年版)(以下简称“2021版病种分值表”)中新生儿病种组合存在的问题及广州市社会医疗保险按病种分值付费病种分值表(2022年版)(以下简称“2022版病种分值表”)修订的内容,论证2022版病种分值表实施后新生儿病种设置的合理性。方法:分析2021版病种分值表中新生儿病种组合存在的问题,结合广州市某医保定点医院的新生儿病种结算数据,采用描述性分析及非参数检验比较2022版病种分值表的分值费用与次均费用情况。结果:受医疗机构病案首页数据填报质量的影响,2021版病种分值表中的新生儿病种组合存在入组操作过于细化、分值倒挂、入组诊断未严格区分等问题,2022版病种分值表对上述问题进行修正。经检验,2022版病种分值表能较好地反映实际医疗资源消耗。结论:广州市2022版病种分值表中的新生儿病种组合较2021版更为合理,医疗机构的病案首页数据填报质量有所提升,分值费用更接近临床实际资源消耗,病种分值付费政策优化需要各部门深度参与和协作。Objective:In the context of the revision of the disease classification and payment table in Guangzhou City of Guangdong Province,this study analyzes the issues with the combination of newborn diseases in the 2021 version of the disease classification and payment table for social medical insurance in Guangzhou,and the revised content of the 2022 version,and proves the rationality of neonatal disease types setting after the implementation of the 2022 version.Methods:The paper analyzes the combination of newborn diseases in the 2021 version.Combined with the settlement data of newborn diseases in a designated maternal and child health care medical institution for healthcare security in Guangzhou,descriptive analysis and non-parametric tests were used to compare the DIP score cost and average cost per case in the 2022 version.Results:Due to the quality of data filling in the medical records of medical institutions,there are problems with the combination of newborn diseases in the 2021 version,such as overly detailed grouping operations,inverted scores,and lack of strict differentiation in grouping diagnosis.The 2022 version has been revised to address these issues.After testing,the 2022 version can better reflect the actual consumption of medical resources.Conclusion:The combination of newborn diseases in the 2022 version is more reasonable than that in the 2021 version.The quality of data filling in the medical records of medical institutions has been improved,and the DIP score cost is closer to the actual clinical consumption.The optimization of DIP policy requires participation and cooperation from various departments.

关 键 词：按病种分值付费 新生儿病种组合 医疗资源消耗 

分 类 号：F840.684[经济管理—保险]