DIP付费下医保基金监管方法与实践  

DIP-based medical insurance fund supervision methods and practices

作　　者：张玉姝 陈一凡 邹作丽 王颖[1] 李明 ZHANG Yushu;CHEN Yifan;ZOU Zuoli;WANG Ying;LI Ming(School of Public Health,Fudan University/NHC Key Laboratory of Health Technology Assessment(Fudan University),Shanghai,200032,PRC)

机构地区：[1]复旦大学公共卫生学院/国家卫生健康委员会卫生技术评估重点实验室(复旦大学),上海市200032 [2]贵州医科大学公共卫生与健康学院,贵州省贵阳市561113 [3]上海市浦东新区周浦医院/上海健康医学院附属周浦医院,上海市201318 [4]上海市东方医院,上海市200092

出　　处：《中国医院》2025年第4期49-52,共4页Chinese Hospitals

基　　金：国家社会科学基金重大项目(22&ZD144);上海市浦东新区卫生健康委研究项目(PW2021A-69);上海健康医学院临床研究中心(22MC2022002)。

摘　　要：目的:了解S市J区医保基金监管现状,分析面临的挑战及优化对策,以保障DIP支付改革顺利推进。方法:收集36所试点医疗机构15日再入院率、出院人次人头比等5年相关数据,并对S市J区医疗保险报销数据库、DIP改革医疗机构信息系统数据库等相关数据进行二次数据采集处理,围绕基金监管体系、方式及客体等进行研究。结果:S市J区搭建了医保综合监督体系,对定点医疗机构实施全覆盖现场检查,监管效果保持较好水平。但改革易出现高套分值等新问题,加剧基金监管人员工作压力,给医保基金智能监管提出了更高的要求。结论:DIP付费下基金监管需要加强专业人员队伍建设,全面深化医保智能监控系统建设,健全医保基金监管指标体系,完善DIP医保支付配套政策。Objective:To understand the current status of medical insurance fund supervision in J District,S City,analyze the challenges faced,and propose optimization strategies to ensure the smooth implementation of DIP-based payment reform.Methods:Data from 36 pilot medical institutions over five years,including the 15-day readmission rate and discharge-to-population ratio,were collected.Secondary data processing was conducted using the medical insurance reimbursement database of J District,S City,and the DIP reform medical institution information system database.The study focused on the fund supervision system,methods,and subjects.Results:J District,S City has established a comprehensive medical insurance supervision system,implementing full-coverage on-site inspections of designated medical institutions,maintaining a relatively high level of regulatory effectiveness.However,new challenges such as high-score optimization have emerged,increasing the workload of fund supervision personnel and raising higher demands for intelligent medical insurance supervision.Conclusion:Under the DIP-based payment system,fund supervision requires strengthening the professional workforce,comprehensively advancing the development of intelligent medical insurance monitoring systems,improving the medical insurance fund supervision indicator system,and refining the supporting policies for DIP-based medical insurance payments.

关 键 词：DIP付费 医保基金 医保支付 基金监管 医保监控 

分 类 号：R197.3[医药卫生—卫生事业管理]