按病种分值付费改革下试点县级医疗机构的运营现况分析  

Current operational status of pilot county-level medical institutions under Diagnosis-Intervention Packet reform

作　　者：毛玫涵 郝嘉琦 祁瑞 MAO Meihan;HAO Jiaqi;QI Rui(School of Public Health,Lanzhou University,Lanzhou,Gansu 730000,P.R.China;Clinical College of Traditional Chinese Medicine,Gansu University of Traditional Chinese Medicine,Lanzhou,Gansu 730000,P.R.China)

机构地区：[1]兰州大学公共卫生学院,兰州730000 [2]甘肃中医药大学中医临床学院,兰州730000

出　　处：《华西医学》2024年第12期1874-1879,共6页West China Medical Journal

基　　金：甘肃省自然科学基金(24JRRA413)。

摘　　要：目的探讨按病种分值付费(Diagnosis-Intervention Packet,DIP)改革对试点县级医院运营的影响,分析医院在DIP改革中可能面临的挑战,提出适应改革的策略。方法收集DIP运行区域甘肃省酒泉市某县级三级甲等公立医院2022年医疗保险参保住院患者的结算清单数据,模拟DIP付费,以入组情况、费用偏差、住院天数、住院费用、DIP支付为相关指标,分析实施DIP改革后医院及各个科室的运营现状。结果DIP付费的实施下,该院整体入组率为98.1%,其中核心组占85.4%,综合组占7.0%,基层组占7.6%。正常费用占比88.9%,偏差费用占比11.1%,其中高倍病例1.9%,低倍病例9.2%。纳入医院所有病例按DIP支付标准为1546.4万元,统筹基金支付金额总和为1998.6万元,DIP支付与按项目付费获得支付的差额为–452.2万元。结论实行DIP付费后该县级医疗机构获得医疗保险支付的差异较大,急需尽快适应DIP支付改革。Objective To explore the impact of Diagnosis-Intervention Packet(DIP)reform on the operation of pilot county-level hospital,analyze the challenges that hospitals may face in DIP reform,and propose strategies to adapt to the reform.Methods The settlement list data of inpatients insured by medical insurance for 2022 from a county-level tertiary public hospital in Jiuquan City,Gansu Province were collected,where DIP was planned to operate.The DIP payment was simulated,and the operational status of the hospital and departments after implementing DIP reform was analyzed based on enrollment status,cost deviation,length of stay,hospitalization expenses,and DIP payment as relevant indicators.Results Under the implementation of DIP payment,the overall enrollment rate of the hospital was 98.1%,including 85.4%in the core group,7.0%in the comprehensive group,and 7.6%in the grassroots group.Normal costs accounted for 88.9%,deviation costs accounted for 11.1%,with high magnification cases accounting for 1.9%and low magnification cases accounting for 9.2%.The payment standard for all cases included in the hospital according to DIP was 15.464 million yuan,the total amount paid by the pooling fund was 19.986 million yuan,and the difference between DIP payment and payment by project was–4.522 million yuan.Conclusion There is a significant difference in the medical insurance payments received by county-level hospitals after implementing DIP payment,and there is an urgent need to adapt to the DIP payment reform as soon as possible.

关 键 词：按病种分值付费 医疗保险改革 县级医疗机构 运营管理 

分 类 号：R197.1[医药卫生—卫生事业管理]