摘要
[目的]研究北京某三级甲等儿科专科医院先天性疾病收治现状,从CHS-DRG视角分析儿童先天性疾病的病种结构和费用特点,为完善儿童健康保障和医保支付提供依据。[方法]汇总该院2021年北京医保先天性疾病患者的病案首页和医保结算数据,分析先天性疾病患者报销待遇,根据DRG分组思路梳理先天性疾病的病种分布,统计相同DRG组内不同年龄患者的医疗费用差异。[结果]2021年北京市将先天性疾病纳入基本医保报销,实际报销比例为59.41%,先天性疾病住院以男性、学龄前儿童为主,手术治疗居多,CMI值为1.09,治疗难度较大,费用较平均水平高;经CHS-DRG分组方案分组,以MD1(睾丸手术)、DC2(耳部其他小手术)和FD3(先天性心脏病介入治疗)居多。同一DRG组6岁以下患者治疗费用高于6岁以上患者。[结论]儿童先天性疾病医保报销待遇得到提高,需结合先天性疾病特点,进一步优化分组方案,结合费用分布细化付费细则,进一步体现儿科诊疗的技术价值。
Objective To study the current treatment of congenital diseases in a 3A grade children s hospital in Beijing.The structure and costs of congenital diseases in children are analyzed from the perspective of CHS-DRG to provide the basis for improving children s health insurance and medical insurance payment.Methods The first page of medical records and settlement data of medical insurance of patients with congenital diseases under the Beijing medical insurance in 2021 were collected in this hospital.The reimbursement of patients with congenital diseases was analyzed.The distribution of congenital diseases was sorted out according to the DRG classification.And the differences in medical expenses of patients of different ages within the same DRG group were calculated.Results In 2021,congenital diseases were included in the reimbursement of basic medical insurance in Beijing,and the actual reimbursement ratio reached 59.41%.Most inpatients with congenital diseases were male and preschool children,and most were treated with surgery.The CMI value was 1.09.The treatment was more difficult and the cost was higher than the average level.MD1(testicular surgery),DC2(other minor surgeries on ears)and FD3(congenital heart disease intervention)were predominant according to CHS-DRG classification scheme.The treatment cost of patients under 6 years old in the same DRG group was higher than that of patients over 6 years old.Conclusions The reimbursement of medical insurance for children with congenital diseases has been improved.It is necessary to further optimize the classification scheme based on the characteristics of congenital diseases,and refine the payment rules based on the cost distribution,so as to further reflect the technical value of pediatric diagnosis and treatment.
作者
那春霞
刘之蕙
高广颖
王东子
付泊迁
NA Chunxia;LIU Zhihui;GAO Guangying;WANG Dongzi;FU Boqian(Medical Insurance Office,National Center for Children s Health,Beijing Children s Hospital,Capital Medical University,Beijing 100045,China;School of Public Health,Capital Medical University,Beijing 100069,China)
出处
《卫生软科学》
2023年第5期87-91,共5页
Soft Science of Health
基金
首都医科大学医院管理研究所2021年度开放性课题—CHS-DRG支付背景下儿童专科医疗机构提升重点病组服务能力和效率的实践研究(2021YGS03)。
关键词
先天性疾病
儿童
DRG
支付方式改革
医保结算
北京
congenital diseases
children
DRG
reform of payment methods
settlement of medical insurance
Beijing
