我国台湾地区住院诊断关联群支付制度改革经验及启示
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摘要
通过对我国台湾地区全民健康保险住院诊断关联群支付制度的核心内容进行深入研究,进一步探讨该制度的实施效果与存在问题,如制度设计缺乏财务风险补偿弹性和实施过渡期、配套措施尚不完善等。在此基础上为全国按疾病诊断相关分组收付费改革制度顺利实施提出政策建议,包括规范支付标准测算方法、明确正常病例与异常病例的界定标准、优化异常病例的支付方式、增加实施过渡期、完善配套措施等。
By comprehensive research of core contents of Taiwan Region Diagnosis Related Groups(Tw-DRGs) payment system, it further discussed implementation effect and existing problems of the system, such as lack of financial risk compensation flexibility and transitional period in the system design, imperfect supporting measures. In order to put forward policy suggestions for the implementation of Chinese Diagnosis Related Groups(C-DRG), including standardizing measurement method of payment standard, clarifying definition standard of normal cases and abnormal cases, optimizing payment method of abnormal cases, adding the transitional period of implementation and improving supporting measures.
By comprehensive research of core contents of Taiwan Region Diagnosis Related Groups(Tw-DRGs) payment system, it further discussed implementation effect and existing problems of the system, such as lack of financial risk compensation flexibility and transitional period in the system design, imperfect supporting measures. In order to put forward policy suggestions for the implementation of Chinese Diagnosis Related Groups(C-DRG), including standardizing measurement method of payment standard, clarifying definition standard of normal cases and abnormal cases, optimizing payment method of abnormal cases, adding the transitional period of implementation and improving supporting measures.
引文
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[3]LU J F R,HSIAO W C.Does universal health insurance make health care unaffordable?Lessons from Taiwan[J].Health aff,2003,22(3):77-88.
[4]CHENG S H,CHIANG T L.The effect of universal health insurance on health care utilization in Taiwan:results from a natural experiment[J].JAMA,1995,278(2):89.
[5]陈佩青,郭年真,黄昱瞳,等.实施全民健康保险住院诊断关联群支付制度对医疗机构之影响[J].台湾公共卫生杂志,2016,35(3):268-280.
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[15]Sloan F A,Morrisey M A,Valvona J.Case shifting and the Medicare Prospective Payment System.[J].American journal of public health,1988,78(5):553-556.
[16]彭颖,金春林,王贺男.美国DRG付费制度改革经验及启示[J].中国卫生经济,2018,37(7):93-96.
[17]卫生福利部.迈向支付制度新纪元,健保推出台湾版DRGs[EB/OL].[2018-04-11].https://www.mohw.gov.tw/fp-3162-27415-1.html.
[18]CHENG S H,CHEN C C,Tsai S L.The impacts of DRG-based payments on health care provider behaviors under a universal coverage system:a population-based study[J].Health policy,2012,107(2-3):202-208.
[19]廖惠华,李伟强,张伟斌,等.台湾导入诊断关联群对医疗利用之影响-以内科系心导管诊断及治疗为例[J].医务管理期刊,2014,15(2):111-127.
[20]罗郁婷,张冠民,董钰琪.DRG为基础前瞻性支付制度对髋关节骨折/置换术的医疗利用与照护结果之影响[J].台湾公共卫生杂志,2015,34(2):180-192.
[21]卫生福利部中央健康保险署.DRG支付制度实施一年之整体成效[EB/OL].[2018-01-23].https://www.google.com/url?q=https://www.mohw.gov.tw/dl-3289-c98cc406-754b-4f1b-b11a-fe1f835e4091.html&sa=U&ved=0ahUKEwi77vu uwO3YAhVD0WMKHf2uCVUQFggEMAA&client=internaluds-cse&cx=012254495936870409035:lzvyrg0mtim&usg=AOvVaw1AfW-T2AaDVZ6qTGj1U-hK.
[22]卫生福利部中央健康保险署.急性后期整合照护计划[EB/OL].[2018-04-20].https://www.nhi.gov.tw/Content_List.aspx?n=5A0BB383D955741C&topn=D39E2B72B0BDFA15.
[23]郎婧婧,于丽华,周海龙,等.C-DRG相对权重、基础费率、服务价格的制定原则和方法[J].中国卫生经济,2017,36(6):18-19.
[24]于保荣.既要长远眼光又要系统思维[J].中国卫生,2018(5):31-32.
[25]吴晶,朱玄,邱晓禹.医疗保险按病种付费的国际借鉴[J].中国医疗保险,2017(11):69-72.
[26]何青,江芹,郎婧婧,等.典型国家和地区DRG实施过渡期经验探讨[J].中国卫生经济,2017,36(11):93-96.
[27]张振忠,江芹,于丽华.全国按疾病诊断相关分组收付费规范的总体设计[J].中国卫生经济,2017,36(6):5-8.
[2]LEE Y C,HUANG Y T,TSAI Y W,et al.The impact of universal National Health Insurance on population health:the experience of Taiwan[J].BMC health services research,2010,10(1):225.
[3]LU J F R,HSIAO W C.Does universal health insurance make health care unaffordable?Lessons from Taiwan[J].Health aff,2003,22(3):77-88.
[4]CHENG S H,CHIANG T L.The effect of universal health insurance on health care utilization in Taiwan:results from a natural experiment[J].JAMA,1995,278(2):89.
[5]陈佩青,郭年真,黄昱瞳,等.实施全民健康保险住院诊断关联群支付制度对医疗机构之影响[J].台湾公共卫生杂志,2016,35(3):268-280.
[6]卫生福利部中央健康保险署.方案问答辑(1)-管理面[EB/OL].[2017-12-05].https://www.nhi.gov.tw/DL.aspx?sitessn=292&u=LzAwMS9VcGxvYWQvMjkyL3JlbGZpbGUvMC81NzA3L2U5MDkxOTc0LTEyNGYtNDBjMC04MjJjLTdkYjNhYTQ0ZThiMC5wZGY%3d&n=5pa55qGI5ZWP562U6LyvKDEpLeeuoe eQhumdoigxMDYuMDEuMTHmm7TmlrApLnBkZg%3d%3d&i co%20=.pdf.
[7]卫生福利部中央健康保险署.Tw-DRGs懒人包[EB/OL].[2017-12-05].https://www.nhi.gov.tw/DL.aspx?sitessn=292&u=LzAwMS9VcGxvYWQvT2xkRmlsZS9OaGlQdWJXZWIvcmVz b3VyY2UvV2ViZGF0YS8zMDE1OV8xX1R3LURSR3Pmh7bk urrljIVfMTA1MDIwMi5wZGY%3d&n=MzAxNTlfMV9Udy1EUkdz5oe25Lq65YyFXzEwNTAyMDIucGRm&ico%20=.pdf.
[8]卫生福利部中央健康保险署.Tw-DRGs分类表4.0版修订重点[EB/OL].[2017-12-05].https://www.nhi.gov.tw/DL.aspx?sitessn=292&u=LzAwMS9VcGxvYWQvMjkyL3JlbGZpbGUv MC81NjkwLygyKXR3LWRyZ3PliIbpoZ7ooag0LjDniYjkv67oq ILph43pu54oMTA2LjA5LjEx5L%2bu6KiCKS5wZGY%3d&n=KDIpVHctRFJHc%2bWIhumhnuihqDQuMOeJiOS%2fruiog umHjem7nigxMDYuMDkuMTHkv67oqIIpLnBkZg%3d%3d&i co%20=.pdf.
[9]卫生福利部中央健康保险署.ICD-10-CM/PCS版Tw-D RG支付通则[EB/OL].[2018-02-28].https://www.nhi.gov.tw/DL.aspx?sitessn=292&u=LzAwMS9VcGxvYWQvMjkyL3JlbGZpb GUvMC81NjkyLzIwMTTlubTniYhfaWNkLTEwLWNtLXBjc190dy1kcmdz5pSv5LuY6YCa5YmHKOiNieahiCkoMTA2LjEyLjI45pu05pawKS5wZGY%3d&n=MjAxNOW5tOeJiF9JQ0QtMTAtQ00tUENTX1R3LURSR3PmlK%2fku5jpgJrliYco6I2J5qGIKSgxMDYuMTIuMjjmm7TmlrApLnBkZg%3d%3d&ico%20=.pdf.
[10]卫生福利部中央健康保险署.ICD-10-CM/PCS版Tw-DRGs分类表3.4版[EB/OL].[2017-12-05].https://www.nhi.gov.tw/DL.aspx?sitessn=292&u=LzAwMS9VcGxvYWQvMjkyL3JlbGZpbGUvMC81Njk0L3R3LWRyZ3PliIbpoZ7ooagzLjTniYh pY2QtMTBfMTA2MDkzMC5wZGY%3d&n=VHctRFJHc%2b WIhumhnuihqDMuNOeJiElDRC0xMF8xMDYwOTMwLnBkZg%3d%3d&ico%20=.pdf.
[11]卫生福利部中央健康保险署.各部门总额历年点值[EB/OL].[2018-02-14].https://www.nhi.gov.tw/DL.aspx?sitessn=292&u=LzAwMS9VcGxvYWQvMjkyL3JlbGZpbGUvMC8xMDI1Mi%2flkITnuL3poY3lkITlraPlhazlkYrpu57lgLwtMTA2MTIuc GRm&n=5ZCE57i96aGN5ZCE5a2j5YWs5ZGK6bue5YC8LTEwNjEyLnBkZg%3d%3d&ico%20=.pdf.
[12]卫生福利部统计处.统计资料Q&A[EB/OL].[2018-02-07].https://dep.mohw.gov.tw/DOS/cp-1716-14931-113.html.
[13]卫生福利部中央健康保险署.全民健康保险住院诊断关联群(Tw-DRG)案件审查通则[EB/OL].[2017-12-05].https://www.nhi.gov.tw/Content_List.aspx?n=89E12C38F2C0264C&topn=D39E2B72B0BDFA15&upn=713BF0A3048866BF.
[14]卫生福利部中央健康保险署.7项不适当出院状态说明[EB/OL].[2017-12-05].https://www.nhi.gov.tw/DL.aspx?sites sn=292&u=LzAwMS9VcGxvYWQvT2xkRmlsZS9OaGlQdWJXZWIvcmVzb3VyY2UvV2ViZGF0YS8yNzU3NV8xX0RSR%2baUr%2bS7mOWItuW6puS4izfpoIXkuI3pgannlbblh7rpmaLni4DmhYvoqqrmmI4xMDUxMTE2LnBkZg%3d%3d&n=Mjc1NzVfMV9EUkfmlK%2fku5jliLbluqbkuIs36aCF5LiN6YGp55W25Ye66Zmi54uA5oWL6Kqq5piOMTA1MTExNi5wZGY%3d&ico%20=.pdf.
[15]Sloan F A,Morrisey M A,Valvona J.Case shifting and the Medicare Prospective Payment System.[J].American journal of public health,1988,78(5):553-556.
[16]彭颖,金春林,王贺男.美国DRG付费制度改革经验及启示[J].中国卫生经济,2018,37(7):93-96.
[17]卫生福利部.迈向支付制度新纪元,健保推出台湾版DRGs[EB/OL].[2018-04-11].https://www.mohw.gov.tw/fp-3162-27415-1.html.
[18]CHENG S H,CHEN C C,Tsai S L.The impacts of DRG-based payments on health care provider behaviors under a universal coverage system:a population-based study[J].Health policy,2012,107(2-3):202-208.
[19]廖惠华,李伟强,张伟斌,等.台湾导入诊断关联群对医疗利用之影响-以内科系心导管诊断及治疗为例[J].医务管理期刊,2014,15(2):111-127.
[20]罗郁婷,张冠民,董钰琪.DRG为基础前瞻性支付制度对髋关节骨折/置换术的医疗利用与照护结果之影响[J].台湾公共卫生杂志,2015,34(2):180-192.
[21]卫生福利部中央健康保险署.DRG支付制度实施一年之整体成效[EB/OL].[2018-01-23].https://www.google.com/url?q=https://www.mohw.gov.tw/dl-3289-c98cc406-754b-4f1b-b11a-fe1f835e4091.html&sa=U&ved=0ahUKEwi77vu uwO3YAhVD0WMKHf2uCVUQFggEMAA&client=internaluds-cse&cx=012254495936870409035:lzvyrg0mtim&usg=AOvVaw1AfW-T2AaDVZ6qTGj1U-hK.
[22]卫生福利部中央健康保险署.急性后期整合照护计划[EB/OL].[2018-04-20].https://www.nhi.gov.tw/Content_List.aspx?n=5A0BB383D955741C&topn=D39E2B72B0BDFA15.
[23]郎婧婧,于丽华,周海龙,等.C-DRG相对权重、基础费率、服务价格的制定原则和方法[J].中国卫生经济,2017,36(6):18-19.
[24]于保荣.既要长远眼光又要系统思维[J].中国卫生,2018(5):31-32.
[25]吴晶,朱玄,邱晓禹.医疗保险按病种付费的国际借鉴[J].中国医疗保险,2017(11):69-72.
[26]何青,江芹,郎婧婧,等.典型国家和地区DRG实施过渡期经验探讨[J].中国卫生经济,2017,36(11):93-96.
[27]张振忠,江芹,于丽华.全国按疾病诊断相关分组收付费规范的总体设计[J].中国卫生经济,2017,36(6):5-8.