基于门诊病例分组的费用标准测定及门诊支付改革研究  

Study on the Measurement of Cost Standards and the Reform of Outpatient Payment based on Outpatient Case Grouping

作　　者：陈洁[1,2] 许晨虹 林振威 CHEN Jie;XU Chenhong;LIN Zhenwei(Zhejiang Cancer Hospital,Hangzhou Zhejiang 310022,China;不详)

机构地区：[1]浙江省肿瘤医院,浙江杭州310022 [2]浙江省省级医院管理中心,浙江杭州310002

出　　处：《卫生经济研究》2024年第8期49-52,共4页

基　　金：浙江省卫生健康科技计划“基于门诊病例分组(APG)的支付标准测定及费用控制研究”(2022KY141)。

摘　　要：目的:基于决策树原理测定门诊费用标准,为门诊医保支付改革提供定价参考。方法:采集2023年1—6月共41 371份肺恶性肿瘤门诊病例数据,利用决策树模型进行门诊病例分组并测定标准费用,在分类基础上对超线费用进行分析。结果:“是否用药”“是否治疗”“是否检验”等5个影响因素纳入分组规则,共形成8个门诊病例组合;研究得出的标准总费用对实际总费用的解释效果达到71.07%,10.76%的线外病例消耗了24.23%的医疗资源。结论:推进门诊医保支付改革,控制门诊医疗费用过快增长,从而完善医保基金长效平衡机制,实现医疗、医保、医药高质量协同发展。Objective To determine the outpatient cost standard based on the principle of decision tree,and provide pricing reference for outpatient medical insurance payment reform.Methods A total of 41371 outpatient cases of pulmonary malignant tumors were collected from January to June 2023,and the decision tree model was used to group the outpatient cases and determine the standard cost,and the over-the-line cost was analyzed on the basis of classification.Results Five influencing factors such as"whether to use drugs","whether to treat",and"whether to test"were included in the grouping rules,resulting in a total of 8 outpatient case combinations.The explanatory effect of the standard total cost obtained from the study on the actual total cost reached 71.07%,and 10.76%of the out-of-line cases consumed 24.23%of the medical resources.Conclusion It is necessary to promote the outpatient medical insurance payment reform,and control the excessive growth of outpatient medical costs,in order to improve the long-term balance mechanism of the medical insurance fund and realize the high-quality synergistic development of medical care,medical insurance and medicine.

关 键 词：门诊病例分组 门诊费用 决策树 门诊医保支付改革 

分 类 号：R19[医药卫生—卫生事业管理]