金华市门诊APG点数法付费组合政策探析  

Analysis of the Payment Combination Policy of APG Points Method in Outpatient Departments of Jinhua City

作　　者：于淼 妥宏武 杨燕绥 刘英杰 吴冠频 金华强 江小州 

机构地区：[1]清华大学医学院,北京100084 [2]广州工商学院,广州510030 [3]清华大学医院管理研究院,深圳518071 [4]国新健康保障服务集团股份有限公司,北京100028 [5]金华市医疗保障局,金华321000

出　　处：《中国医疗保险》2024年第10期68-77,共10页China Health Insurance

基　　金：广州市哲学社科规划2023年度课题“广州健全多层次社会保障体系研究”(2023GZQN68)。

摘　　要：目的:通过分析金华市门诊APG点数法付费组合政策,探索如何建立有效的医保门诊支付机制。方法:在总结门诊病例分组(APG)原理的基础上,基于服务可及性、质量与安全、效率和支付三个价值构建政策绩效评估框架,使用2019—2023年金华市门诊医保基金支出和门诊付费数据,运用定量评估的方法,对金华市“APG点数+人头打包”的门诊组合付费政策实施效果进行评估。结果:医疗费用和医保基金增长率在7%左右,职工医保和居民医保均有结余,包括门诊APG预算总额结余;异地就医占比较低;一级医疗机构服务能力和运行效率在增加;APG病组结余率上升,门诊费用结构逐渐优化,医疗服务质量稳定,门诊统筹与住院统筹未发生互补效应。结论:金华市将签约服务和未签约服务人群分开,对前者嵌入疾病风险加权和分组预算,提高了医保基金配置的科学性、公平性且夯实了医保健康绩效考核的基础,促进了门诊服务提质增效,调动了基层医疗机构的积极性,成为市医保支付系统工程的重要组成部分。今后需进一步探索住院DRG与门诊APG的合理对接与智能化操作,以提高分组科学性和降低操作成本。Objective:The paper explores how to establish an effective payment mechanism for medical insurance outpatient service by analyzing the payment combination policy of APG points in Jinhua City.Methods:On the basis of summarizing the principle of APG,the policy performance evaluation framework is constructed based on the three values of service accessibility,quality and safety,and efficiency and payment.The data of Jinhua municipal medical insurance fund expenditure and outpatient payment from 2019 to 2023 are used,and the methods of quantitative evaluation are applied to evaluate the effect of the outpatient combination payment policy of"APG points plus capitation package"in Jinhua City.Results:The growth rate of medical expenses and medical insurance fund was about 7%,and there was a balance of employees’medical insurance and residents’medical insurance,including the total budget balance of outpatient APG.The proportion of medical treatment in different places is relatively low.The service capacity and operational efficiency of Level-I medical institutions are increasing.The balance rate of APG patients increased,the structure of outpatient expenses was gradually optimized,the quality of medical services was stable,and there was no complementary effect between outpatient and inpatient coordination.Conclusion:Jinhua City separated contracted service and uncontracted service groups,and embedded disease risk weighting and group budget into the former,which improved the scientific and fair allocation of medical insurance funds,consolidated the foundation of medical insurance performance assessment,promoted the quality and efficiency of outpatient services,stimulated the enthusiasm of primary medical institutions,and became a part of the medical insurance payment systematic project of Jinhua City.In the future,it is necessary to further explore the rational docking and intelligent operation of inpatient DRG and outpatient APG,so as to improve the scientific grouping and reduce the operating cost.

关 键 词：门诊病组分值APG 人头加权分组预算 医保支付方式 

分 类 号：F840.684[经济管理—保险] C913.7[社会学]