按病种分值付费下医疗机构医保结算支付率影响因素研究——基于市域的实证分析  

Study on the Factors Influencing the Medical Insurance Settlement Payment Rate Under the DIP Payment——Empirical Analysis Based on G City

作　　者：江宽列 张涛 路伟 刘嘉祺 李璐[4] 刘静[1] 

机构地区：[1]汕头大学医学院粤北人民医院,韶关512026 [2]海南医科大学公共卫生学院,海口571199 [3]杭州师范大学公共卫生学院,杭州311121 [4]广州医科大学卫生管理学院,广州511436

出　　处：《中国医疗保险》2025年第4期90-95,共6页China Health Insurance

基　　金：国家自然科学基金青年项目“价值共创视角下社区慢病服务旅程质量评价模型及提升策略研究”(72204153);国家中医药管理局监测统计中心深化医改中医药政策研究项目“基于价值导向的DIP支付下中医优势病种分值构成测算模型研究”(YGZXKT2024348);广东省教育厅普通高校青年创新人才项目“基于关系协调理论的广东省整合型卫生服务体系高质量协作研究”(2022WQNCX056)。

摘　　要：目的:分析DIP支付方式改革下医疗机构医保结算支付率现状及其影响因素,为完善DIP支付政策、促进医疗机构优化内部运营及合理补偿提供依据。方法:基于2024年1—3月G市158家医疗机构DIP结算数据,运用多元线性回归分析医保结算支付率的影响因素。结果:实证结果显示,住院费用越低、住院天数越短,医保结算支付率越高(P<0.05);三级医疗机构及核心病种医保结算支付率显著偏低(P<0.05);职工医保相较居民医保、非保守治疗相较保守治疗的医保结算支付率更高(P<0.05)。结论:医保机构可进一步优化支付政策设计,动态调整病种分值,完善特例单议机制,增强支付公平性与科学性,同时,完善居民医保基金筹资、待遇标准的动态调整机制,保障基金长期稳定运行;医疗机构应实行精细化管理,优化成本核算,加强内部监督管理,提升对DIP支付方式改革的适应能力。Objective:The paper analyzes the current status and influencing factors of the medical insurance settlement payment rate under the DIP payment system,providing a basis for improving the DIP payment policy,optimizing internal operations in medical institutions,and ensuring reasonable compensation.Methods:Based on the DIP settlement data from 158 medical institutions in G City from January to March 2024,multiple linear regression analysis was used to investigate the factors affecting the medical insurance settlement payment rate.Results:The empirical results show that lower hospitalization costs,shorter hospital stays were associated with higher medical insurance settlement payment rate(P<0.05).Medical insurance settlement payment rates were significantly lower for tertiary medical institutions and core diseases(P<0.05).The medical insurance settlement payment rate of employees' medical insurance is higher than that of residents' medical insurance,and non-conservative treatment is higher than that of conservative treatment(P<0.05).Conclusion:Healthcare security institutions should optimize payment policy design,dynamically adjust disease category values,improve the mechanism of special case negotiation,enhance the fairness and scientificity of payments,and improve the dynamic adjustment mechanism for the fundraising of the residents' medical insurance fund and benefit standards,ensuring the stable operation of the fund in the long term.Medical institutions should implement refined management,optimize cost accounting,strengthen internal supervision and management,and enhance their adaptability to the DIP payment system reform.

关 键 词：DIP 按病种分值付费 医保结算支付率 医保支付方式改革 

分 类 号：F840.684[经济管理—保险]