DRG付费改革下医院医保结算率的影响因素研究——基于医院视角的实证分析  

Research on the Influencing Factors of Hospital Medical Insurance Settlement Rate Under the DRG Payment Method Reform——An Empirical Analysis from the Perspective of Hospitals

作　　者：刘雨欣 罗毅[1] 杨莹[2] 毛宗福[3,4] 

机构地区：[1]华中科技大学同济医学院附属同济医院,武汉430030 [2]华中科技大学同济医学院护理学院,武汉430030 [3]武汉大学董辅礽经济社会发展研究院,武汉430071 [4]武汉大学全球健康研究中心,武汉430071

出　　处：《中国医疗保险》2024年第8期60-66,共7页China Health Insurance

基　　金：国家自然科学基金青年项目“医保战略性购买视角下慢性病多层次门诊用药保障的经济效应与健康效应研究”(72404098)。

摘　　要：目的:基于医院视角分析DRG支付方式改革下影响医保结算率的因素,为提高医院服务质量与效率提供实证依据。方法:以S市同批实施DRG支付方式改革的12家医院为研究样本,通过医保结算系统采集2022年DRG支付病例医保结算清单数据,包括患者个人信息、疾病及诊治信息、DRG分组及住院费用信息等。构建“病组-医院”面板数据集,以医院单个病组的医保结算率为因变量,从费用特征、医院特征、病例类型特征三个维度选取自变量,以患者年龄、病组调整系数为控制变量,区分居民和职工两种医保类型,运用病组间固定效应模型分析医保结算率的影响因素。结果:在费用特征维度,次均住院费用(β居民=-51.70,P<0.01;β职工=-39.18,P<0.01)、药占比(β居民=-0.77,P<0.01;β职工=-0.43,P<0.01)与结算率呈显著负向关联,政策范围内费用占比(β居民=1.12,P<0.01;β职工=0.71,P<0.01)与结算率呈显著正向关联;在医院特征维度,三级医院较二级医院(β居民=7.79,P<0.01;β职工=9.33,P<0.01)、民营医院较公立医院(β居民=22.16,P<0.01;β职工=13.83,P<0.01)结算率更高;在病例类型特征维度,低倍率病例占比(β居民=0.09,P<0.10;β职工=0.10,P<0.05)、住院大于60天病例占比(β居民=1.30,P<0.01;β职工=0.88,P<0.01)与结算率呈正向关联,而高倍率病例占比(β居民=-0.21,P<0.10;β职工=-0.29,P<0.01)与结算率呈负向关联。结论:降低医疗费用水平、优化医疗费用结构(如提升政策范围内费用占比、降低药占比)有利于增加结算率。二级医院、公立医院应通过提升医疗效率、医院内部管理效能等方式,提高DRG结算率。另外,医保部门需进一步优化不同类型病例的结算规则,引导医院诊疗行为更加合理和高效。Objective:From the perspective of hospitals,this paper analyzes the factors affecting the settlement rate of medical insurance under the DRG payment method reform and provides an empirical basis for improving the service quality and efficiency of hospitals.Methods:Taking the 12 hospitals in City S that have implemented the DRG payment method reform as research samples,the medical insurance settlement list data of DRG payment cases from 2022 were collected through the medical insurance settlement system,including patients'personal information,disease diagnosis and treatment information,grouping and hospitalization cost information.A patient-hospital panel dataset was constructed,which takes the medical insurance settlement rate of a single patient group in a hospital as the dependent variable,selects independent variables from the three dimensions of cost characteristics,hospital characteristics and case type characteristics,and takes patient age and the adjustment coefficient of the patient group as the control variables,distinguishes the two types of medical insurance,i.e.residents and employees,and analyzes the influencing factors of the medical insurance settlement rate by the fixed effect model between patient groups.Results:In the cost characteristic dimension,the average inpatient cost(βresidents=-51.70,P<0.01;βemployee=-39.18,P<0.01),the proportion of drug costs(βresidents=-0.77,P<0.01;βemployee=-0.43,P<0.01)was negatively correlated with the settlement rate,and the proportion of expenses within the policy scope(βresidents=1.12,P<0.01;βemployee=0.71,P<0.01)was positively correlated with settlement rate.In the characteristic dimension of hospital,the tertiary hospital was higher than the secondary hospital(βresidents=7.79,P<0.01;βemployee=9.33,P<0.01),private hospitals was higher than public hospitals(βresidents=22.16,P<0.01;βemployee=13.83,P<0.01)the settlement rate was higher.In the characteristic dimension of case type,the proportion of extremely low-cost cases(βresidents=0.09,P<0.10;βemploye

关 键 词：DRG 医保结算率 固定效应模型 影响因素 

分 类 号：F840.684[经济管理—保险]