摘要
目的探讨诊断相关分组预付费(DRGs-PPS)和病种分值付费(DIP)对医院医保支付费用的影响。方法以2019年医保部门按DIP实际付费总额为标准,模拟按照DRG支付每例住院病人应获得的补偿费用,并将DRG支付和DIP支付费用与病人实际花费费用对比,评价两种付费方法下医保支付费用与实际花费费用的差异,判断哪种付费方式更加符合实际情况。结果该次支付实践中,按DRG支付费用与病人实际花费的拟合度高于DIP支付,特别是病种分值付费中的综合病种组,医保返回报销费用与实际花费的差异较大,拟合度低于按DRG支付,对整个病例拟合度影响较大。在排除这一部分病例之后,病种分值付费的拟合度仍然略弱于DRG支付。结论目前,国家医保局大力推进病种分值付费,DRG支付在部分省市试点,就该次分析来看DRG支付的支付费用与医院实际发生的费用更为接近,更容易被医院和病人接受。如果实施病种分值付费,应特别注意综合病组的合理设置。在未来值得探索两种方法取长补短,相互融合的可能性。
Objective To explore the respective impacts of diagnosis-related groups prospective payment system(DRGs-PPS) and diagnosis-intervention packet(DIP) on medical insurance expenses. Methods Taking the actual total amount of DIP payment by the medical insurance department in 2019 as the standard, we simulated the reimbursed expenses of each inpatient according to DRGs-PPS payment, then compared DRG payment, DIP payment with patients’ actual hospital expenses, evaluated the respective differences and determined which payment was more practical. Results In this payment practice, the goodness of fit between DRGs-PPS payment and the actual payment was higher than that between DIP payment and the actual payment, which was more obvious in comprehensive diseases group of DIP. In this group, there was a great difference between the reimbursed expenses and the actual expenses, whose goodness of fit was lower than DRG payment and had a great impact on the goodness of fit of all cases. With exclusion of this part of cases, the goodness of fit of DIP was still slightly lower than that of DRGs-PPS. Conclusions At present National Healthcare Security Administration vigorously promotes DIP and DRGs-PPS is also practiced in some cities. According to this study and analysis, payment by DRGs-PPS is closer to the actual hospital expenses, which is relatively easier to be accepted by hospitals and patients. If DIP is implemented, importance should be attached to the reasonable setting of comprehensive diseases group. In the future, it is worth exploring the possibility of mutual integration of the two payments.
作者
韩芳
胡伟
赵静怡
HAN Fang;HU Wei;ZHAO Jingyi(Guangdong Provincial People’s Hospital Zhuhai Hospital(Zhuhai Goldenbay Center Hospital),Zhuhai,Guangdong 519040,China;Government Affairs Service Center of Health Commission of Guangdong Province,Guangzhou,Guangdong 510000,China)
出处
《中国农村卫生事业管理》
2021年第12期864-868,共5页
Chinese Rural Health Service Administration
基金
珠海市医学科研基金项目(ZH3310200049PJL)。
关键词
诊断相关分组(DRGs)
预付费
病种分值付费(DIP)
医保支付
综合病种
Diagnosis-related groups
Prospective payment system
Diagnosis intervention packet
Medical insurance expenses
Comprehensive diseases
