医保支付方式改革对医疗服务及费用的影响分析——以金华市为例  

The impact of medical insurance payment reform on medical services and costs:A case study of Jinhua

作　　者：于淼[1] 李泽耀 妥宏武 杨燕绥 吴冠频 金华强 江小州 YU Miao;LI Ze-yao;TUO Hong-wu;YANG Yan-sui;WU Guan-pin;JIN Hua-qiang;JIANG Xiao-zhou(School of Basic Medical Sciences,Tsinghua University,Beijing 100084,China;Institute for Hospital Management of Tsinghua University,Beijing 100084,China;Guangzhou College of Technology and Business,Guangzhou Guangdong 528138,China;Jinhua Healthcare Security Administration,Jinhua Zhejiang 321000,China)

机构地区：[1]清华大学基础医学院,北京100084 [2]清华大学医院管理研究院,北京100084 [3]广州工商学院,广东广州528138 [4]金华市医疗保障局,浙江金华321000

出　　处：《中国卫生政策研究》2025年第1期43-50,共8页Chinese Journal of Health Policy

基　　金：广州市哲学社科规划2023年度课题(2023GZQN68)。

摘　　要：目的:实证分析医保支付方式改革冲击下门诊与住院服务之间的关系,验证改革效果。方法:利用金华市8个区县2020—2022年医疗服务与医保支付数据,构建门诊住院固定效应模型,分析医保支付方式改革对医疗服务及费用的影响。结果:DRG支付对住院人次有显著的正向影响,对职工医保住院费用有显著的负向影响;“人头打包+门诊病例分组付费”对住院人次有显著的负向影响,对城乡居民医保住院费用有显著的负向影响;门诊支付与门诊人次的交互项对职工医保住院人次有显著的负向影响,门诊支付与门诊费用的交互项对整体和职工医保住院费用有显著的负向影响。结论:DRG支付改革带来了住院人次的上升,降低了职工医保住院费用;门诊“人头打包+门诊病例分组付费”支付改革起到了降低住院人次的作用,并降低了城乡居民医保住院费用,减缓了门诊与住院之间的互补效应。Objective:This study empirically analyzes the relationship between outpatient and inpatient services under the impact of healthcare payment reform,and evaluates the effects of the reform.Methods:Data from healthcare services and basic medical insurance payments in eight districts of Jinhua City from 2020 to 2022 were used.A fixed-effects model for outpatient and inpatient services was constructed to analyze the impact of healthcare payment reforms and outpatient services on inpatient services.Results:The DRG-based payment had a significant positive effect on inpatient visits and a significant negative effect on employee basic medical insurance inpatient costs.The“capitation+APG”outpatient payment policy had a significant negative effect on inpatient visits and a significant negative effect on residents'basic medical insurance inpatient costs.The interaction between outpatient payment and outpatient visits had a significant negative effect on employee basic medical insurance inpatient visits,while the interaction between outpatient payment and outpatient costs had a significant negative effect on both overall and employee inpatient costs.Conclusions:The DRG payment reform led to an increase in inpatient visits and a reduction in employee basic medical insurance inpatient costs.The outpatient“capitation+APG”payment reform reduced inpatient visits and lowered residents'basic medical insurance inpatient costs,thereby slowing down the complementary effect between outpatient and inpatient services.

关 键 词：门诊统筹 门诊病例分组付费 按人头付费 

分 类 号：R197[医药卫生—卫生事业管理]