DRG付费下医疗服务供方道德风险表现与防范对策  

Moral Hazard Manifestations and Preventive Countermeasures of Medical Service Providers under DRG Payment

作　　者：杨松[1] 彭美华[2] 钟艳红 吴婧文 周望苏 潘雪冬 李希 肖远会 YANG Song;PENG Meihua;ZHONG Yanhong;WU Jingwen;ZHOU Wangsu;PAN Xuedong;LI Xi;XIAO Yuanhui(The Third Affiliated Hospital of Chengdu Medical Colleg/Chengdu Pidu District People's Hospital,Chengdu Sichuan 611730,China;不详)

机构地区：[1]成都医学院第三附属医院·成都市郫都区人民医院,四川成都611730 [2]成都中医药大学管理学院,四川成都611137 [3]眉山市医疗保障事务中心,四川眉山620020

出　　处：《卫生经济研究》2024年第8期53-57,共5页

基　　金：四川中医药大健康产业发展与乡村振兴研究中心重点项目“支持中医药传承创新发展的医保DRG支付政策优化研究”(DJKZD202301);四川省科技厅“四川省基本医保DRG付费方式改革:制度、成效与对策研究”(2021JDR0312);杏林学者项目“乡村振兴战略背景下紧密型县域医共体建设:成效、困境与对策研究”(XCZX2022017)。

摘　　要：目的:梳理医保支付方式改革下医疗服务供方道德风险的行为表现,提出防范的对策建议。方法:收集35家样本医院DRG结算数据,对编码人员进行问卷调查,对相关部门工作人员进行访谈,探究医疗服务供方道德风险的疑点与特征。结果:DRG付费引发医疗服务供方新的道德风险行为,在医疗服务前期、中期、后期有不同的表现形式,给患者、医保基金和医疗机构造成了不利影响。结论:DRG付费下要加强对医疗服务供方监管,创新监管模式,完善医保沟通渠道,建立协商谈判机制,加强诊疗规范,提高编码能力,防范新型道德风险行为。Objective To sort out the behavioral manifestations of moral hazard of medical service providers under the reform of health insurance payment method,and to put forward preventive countermeasures.Methods Through collecting DRG settlement data from 35 sample hospitals,conducting questionnaire surveys on coders and interviews with staff of relevant departments,the suspicions and characteristics of moral hazard of medical service providers were explored.Results DRG payment has triggered new moral risk behaviors on the supply side of medical services,which had different manifestations in the pre,mid,and late stages of medical services,and adversely affected patients,health insurance funds,and medical institutions.Conclusion Under DRG payment,it is necessary to strengthen the supervision of medical service providers,innovate the supervision model,improve the communication channel of medical insurance,establish the consultation and negotiation mechanism,strengthen the diagnosis and treatment standards,improve the coding ability,and prevent the new type of moral risk behavior.

关 键 词：DRG 医疗服务供方 道德风险 靶点监管 

分 类 号：R19[医药卫生—卫生事业管理]