天津市参保糖尿病门特患者按人头付费模式探讨及效果评价
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摘要
目的探讨按人头付费模式控制参保糖尿病(DM)门诊特殊病种(简称门特)患者门诊费用的效果,旨在为该政策的进一步完善提供科学依据。方法从天津市医疗保险数据库中选取2013年1月1日至2014年12月31日天津市全部871 371例次DM门特患者就诊记录,收集性别、年龄、医保类型、疾病诊断、是否参加按人头付费模式、医院级别和各项门诊费用等相关信息。按照患者是否参加按人头付费分为参加按人头付费的DM门特组(简称按人头付费组,9 505例次)和未参加按人头付费的DM门特组(简称门特组,共861 866例次)。用R 3.4.2统计学软件进行Wilcoxon秩和检验和χ2检验。采用多因素logistic回归分析患者参加按人头付费的影响因素。采用多重线性回归分析DM门诊费用的影响因素。采用倾向性评分匹配法及双重差分模型评估按人头付费模式实施后,DM患者门诊费用的变化情况。结果共871 371例次DM门特患者就诊记录纳入本研究。其中男性439 426例次(50.43%),女性431 945例次(49.57%)。年龄中位数为60岁(P25～P75:54～68岁)。2013年天津市DM门诊总费用约27亿元,2014年约33亿元。多因素logistic回归分析结果显示,年龄越大(OR=1.008,95%CI:1.005～1.010),并发症数目越多(OR=1.365,95%CI:1.338～1.392),在二级医院就诊(OR=2.496,95%CI:2.332～2.671),医保类型为城镇职工医保(OR=4.824,95%CI:4.156～5.598),男性患者(OR=1.098,95%CI:1.037～1.163)参加人头付费的可能性越大。多重线性回归分析结果显示,年龄、性别、医保类型、并发症数目、医院级别和是否参加按人头付费是DM患者各项门诊费用的影响因素(P<0.05)。倾向性评分匹配前,按人头付费组和门特组在性别、年龄、并发症数目、医保类型和医院级别的差异均有统计学意义(P<0.05);倾向性评分匹配后,两组间以上因素的差异均无统计学意义(P>0.05),且按人头付费组的药品费、检查费、治疗费和门诊总费用均明显高于门特组。双重差分结果显示,2014年天津市参加按人头付费模式的DM患者各项门诊费用均高于门特患者,其中全年平均药品费高出2 228.86元/例次,检查费高出83.03元/例次,治疗费高出6.10元/例次,门诊总费用高出2 368.18元/例次,差异均有统计学意义(P<0.05)。结论按人头付费模式对DM门特患者各项门诊费用的控制效果有限,建议各部门加强监管,建立有效机制以完善按人头付费政策,在控制医疗费用的同时,使患者得到更好的医疗服务。
Objective To explore the effect of capitation mode in insured diabetic mellitus(DM) outpatients in Tianjin,and to provide the scientific basis for improving the policy. Methods Total 871 371 records of DM outpatients in Tianjin from January 1 of 2013 to December 31 of 2014 were collected from Tianjin Health insurance database. The data of gender,age,type of insurance,disease diagnosis,capitation,hospital level,outpatients cost and so on were collected. The subjects were divided into two groups:capitation group(9 505 cases) and non-capitation group(861 866 cases). The χ2 tests and Wilcoxon rank test were used to analyze the data;the multivariate logistic regression was used to analyze the influencing factors of capitation mode;the multiple linear regression was used to analyze the influencing factors of DM outpatient expenses;the propensity score matching and difference-in-differences models were used to evaluate the variation of DM outpatient medical records after the implementation of capitation. The used software was R 3.4.2 statistics software. Results A total of 871 371 medical records of DM patients(439 426 males,50.43%;431 945 females,49.57%) were included in the analysis. The median age was 60 years old(P25-P75:54-68 years old). The total DM outpatient costs in Tianjin reached about 2.7 billion yuan in 2013 and 3.3 billion yuan in 2014. The results of multivariate logistic regression showed that age(OR=1.008,95%CI:1.005-1.010),complications(OR=1.365,95%CI:1.338-1.392),hospital level i.e. the secondary hospital(OR=2.496,95%CI:2.332-2.671),urban employees with medical insurance(OR=4.824,95%CI:4.156-5.598),male(OR=1.098, 95%CI:1.037-1.163) were influencing factors of participation in capitation mode,P<0.05. Multiple linear regression analysis showed that age, gender, type of health insurance, complications, hospital level and participation in capitation were the influencing factors of DM outpatient expenses(P<0.05). There were significant differences of gender,age,number of complications,type of medical insurance and hospital level between the two groups before PSM(P <0.05). But there were no significant differences in the above factors between the two groups after PSM(P>0.05) and the median drug costs,examination costs,treatment costs and total outpatient costs in capitation group were significantly higher than those in the control group after PSM. DM outpatient expenses in the capitation group were significantly higher than those in the control group by difference-in-differences analysis in 2014. The annual drug expenses of DM outpatients were higher(RMB 2 228.86 Yuan/case) than those patients with special outpatient services. The annual examination expenses were higher(83.03 Yuan/case).The treatment expenses were higher(6.10 Yuan/case). The total outpatient expenses were higher(2 368.18 Yuan/case).Conclusion The control effect of DM outpatient expenses by capitation mode was limited. It is suggested to strengthen supervision and to establish an effective mechanism for improving the capitation policy. When medical cost is controlled,the patients can obtain the better medical service.
Objective To explore the effect of capitation mode in insured diabetic mellitus(DM) outpatients in Tianjin,and to provide the scientific basis for improving the policy. Methods Total 871 371 records of DM outpatients in Tianjin from January 1 of 2013 to December 31 of 2014 were collected from Tianjin Health insurance database. The data of gender,age,type of insurance,disease diagnosis,capitation,hospital level,outpatients cost and so on were collected. The subjects were divided into two groups:capitation group(9 505 cases) and non-capitation group(861 866 cases). The χ2 tests and Wilcoxon rank test were used to analyze the data;the multivariate logistic regression was used to analyze the influencing factors of capitation mode;the multiple linear regression was used to analyze the influencing factors of DM outpatient expenses;the propensity score matching and difference-in-differences models were used to evaluate the variation of DM outpatient medical records after the implementation of capitation. The used software was R 3.4.2 statistics software. Results A total of 871 371 medical records of DM patients(439 426 males,50.43%;431 945 females,49.57%) were included in the analysis. The median age was 60 years old(P25-P75:54-68 years old). The total DM outpatient costs in Tianjin reached about 2.7 billion yuan in 2013 and 3.3 billion yuan in 2014. The results of multivariate logistic regression showed that age(OR=1.008,95%CI:1.005-1.010),complications(OR=1.365,95%CI:1.338-1.392),hospital level i.e. the secondary hospital(OR=2.496,95%CI:2.332-2.671),urban employees with medical insurance(OR=4.824,95%CI:4.156-5.598),male(OR=1.098, 95%CI:1.037-1.163) were influencing factors of participation in capitation mode,P<0.05. Multiple linear regression analysis showed that age, gender, type of health insurance, complications, hospital level and participation in capitation were the influencing factors of DM outpatient expenses(P<0.05). There were significant differences of gender,age,number of complications,type of medical insurance and hospital level between the two groups before PSM(P <0.05). But there were no significant differences in the above factors between the two groups after PSM(P>0.05) and the median drug costs,examination costs,treatment costs and total outpatient costs in capitation group were significantly higher than those in the control group after PSM. DM outpatient expenses in the capitation group were significantly higher than those in the control group by difference-in-differences analysis in 2014. The annual drug expenses of DM outpatients were higher(RMB 2 228.86 Yuan/case) than those patients with special outpatient services. The annual examination expenses were higher(83.03 Yuan/case).The treatment expenses were higher(6.10 Yuan/case). The total outpatient expenses were higher(2 368.18 Yuan/case).Conclusion The control effect of DM outpatient expenses by capitation mode was limited. It is suggested to strengthen supervision and to establish an effective mechanism for improving the capitation policy. When medical cost is controlled,the patients can obtain the better medical service.
引文
[1]梁雪,刘庆婧,陈康,等. 2型糖尿病伴慢性肾脏病患者住院费用及用药分析[J].中国慢性病预防与控制,2016,24(7):498-501.
[2] International Diabetes Federation. IDF diabetes atlas-7th edition[EB/OL].[2017-12-20]. http://www.diabetesatlas.org/across-theglobe.html.
[3]高子厚,万崇华,蔡乐,等.按DRGs组合方式制定消化系统疾病患者住院费用的研究[J].中国卫生统计,2006,23(4)323-325.
[4]龚卉,崔壮,李长平,等. 2008-2011年天津市2型糖尿病住院费用及其影响因素分析[J].中国卫生统计,2014,31(6):973-975.
[5] Simon B,Ismael C,Carlos A,et al. Diabetes in Mexico:cost and management of diabetes and its complications and challenges for health policy[J]. Glob Health,2013,9(3):1-9.
[6] Austin PC. An introduction to propensity score methods for reducing the effects of confounding in observational studies[J]. Multivariate Behav Res,2011,46(3):399-424.
[7] Austin PC. A critical appraisal of propensity-score matching in the medical literature between 1996 and 2003[J]. Stat Med,2008,27(12):2037-2049.
[8] Lanza ST,Moore JE,Butera NM. Drawing causal inferences using propensity scores:A practical guide for community psychologists[J].Am J community psychol,2013,52(3-4):380-392.
[9]张再生,徐爱好,天津市医疗保险研究会.糖尿病“按人头付费”支付模式效果分析[J].中国农村卫生事业管理,2014,34(9):1058-1060.
[10]胡敏,Yip W,陈文,等.如何提高农村基层医疗服务的效率和质量—宁夏新农合门诊按人头预付制改革设计与效果[J].中国卫生政策研究,2014,7(8):14-18.
[11] Yip W,Powell-Jackson T,Chen W,et al. Capitation combined with pay-for-performance improves antibiotic prescribing practice in rural China[J]. Health Affairs,2014,33(3):502-510.
[12] Nguyen HT,Bales S,Wagstaff A,et al. Getting incentives right? The impact of hospital capitation payment in vietnam[J]. Health Economics,2017,26(2):263-272.
[13]苏红,罗英,李联,等.多种医疗付费方式的研究[J].卫生经济研究,2013,20(3):8-12.
[14]李晓莲.按人头付费门诊医疗费结算方式研究[J].天津社会保险,2013,8(42):33-34.
[15]王桂林.浅析二级公立医院成本管控存在的问题及对策[J].会计师,2016,13(7):58-59.
[16]汤晓莉.英国国家卫生服务制度的起源及几次重大改革[J].中国卫生资源,2001,4(6):280-282.
[17] Matthew T,Amer H,Melissa E,et al. A propensity score-matched analysis of robotic vs open pancreatoduodenectomy on incidence of pancreatic fistula[J]. JAMA Surgery,2017,152(4):327-335.
[2] International Diabetes Federation. IDF diabetes atlas-7th edition[EB/OL].[2017-12-20]. http://www.diabetesatlas.org/across-theglobe.html.
[3]高子厚,万崇华,蔡乐,等.按DRGs组合方式制定消化系统疾病患者住院费用的研究[J].中国卫生统计,2006,23(4)323-325.
[4]龚卉,崔壮,李长平,等. 2008-2011年天津市2型糖尿病住院费用及其影响因素分析[J].中国卫生统计,2014,31(6):973-975.
[5] Simon B,Ismael C,Carlos A,et al. Diabetes in Mexico:cost and management of diabetes and its complications and challenges for health policy[J]. Glob Health,2013,9(3):1-9.
[6] Austin PC. An introduction to propensity score methods for reducing the effects of confounding in observational studies[J]. Multivariate Behav Res,2011,46(3):399-424.
[7] Austin PC. A critical appraisal of propensity-score matching in the medical literature between 1996 and 2003[J]. Stat Med,2008,27(12):2037-2049.
[8] Lanza ST,Moore JE,Butera NM. Drawing causal inferences using propensity scores:A practical guide for community psychologists[J].Am J community psychol,2013,52(3-4):380-392.
[9]张再生,徐爱好,天津市医疗保险研究会.糖尿病“按人头付费”支付模式效果分析[J].中国农村卫生事业管理,2014,34(9):1058-1060.
[10]胡敏,Yip W,陈文,等.如何提高农村基层医疗服务的效率和质量—宁夏新农合门诊按人头预付制改革设计与效果[J].中国卫生政策研究,2014,7(8):14-18.
[11] Yip W,Powell-Jackson T,Chen W,et al. Capitation combined with pay-for-performance improves antibiotic prescribing practice in rural China[J]. Health Affairs,2014,33(3):502-510.
[12] Nguyen HT,Bales S,Wagstaff A,et al. Getting incentives right? The impact of hospital capitation payment in vietnam[J]. Health Economics,2017,26(2):263-272.
[13]苏红,罗英,李联,等.多种医疗付费方式的研究[J].卫生经济研究,2013,20(3):8-12.
[14]李晓莲.按人头付费门诊医疗费结算方式研究[J].天津社会保险,2013,8(42):33-34.
[15]王桂林.浅析二级公立医院成本管控存在的问题及对策[J].会计师,2016,13(7):58-59.
[16]汤晓莉.英国国家卫生服务制度的起源及几次重大改革[J].中国卫生资源,2001,4(6):280-282.
[17] Matthew T,Amer H,Melissa E,et al. A propensity score-matched analysis of robotic vs open pancreatoduodenectomy on incidence of pancreatic fistula[J]. JAMA Surgery,2017,152(4):327-335.