病种权重付费法在医保支付方式改革中的应用研究——“一权重两系数”为核心的病种权重付费法在马鞍山市的实践
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摘要
目的,提高医保基金的使用效率,控制医疗费用不合理增长,提升医疗服务质量,降低参保人员的医疗费用支出,保障医保基金运行安全。方法,建立病种权重付费法,在全市预算总额下,依据权重值对应的基金数计算出各定点医疗机构当期拨付额,对各定点医疗机构住院统筹费用进行分配和结算。结果,实施病种权重付费法以来,通过抽象化病种与基金的直接对应关系,实现了总额控制下基金的合理分配,调动了医疗机构治疗重难疾病的积极性,保障参保人员的切身利益,促使医院主动控制和降低医疗费用,促进医保经办工作由被动变为主动。结论,以"一权重两系数"为核心内容的病种权重付费法(DW—PS)在马鞍山市实施以来,成效明显并具有可持续性。本付费方法借鉴数理科学的概念,成为解决医保支付难题提供了一条有效的经验。
Purpose:In order to improving the efficiency of medical insurance fund,control unreasonable growth of medical expenses,improve the quality of medical services,reduce the medical expenses of insured personnel,and to make the medical insurance fund run safely.Method:Establish the method of paying for the weight of diseases.Under the total budget of the whole city,calculate the current appropriation amount of each designated medical institution according to the fund number corresponding to the weight value,and distribute and settle the overall hospitalization expenses of each designated medical institution.Result:Since the implementation of the disease weight payment method,by abstracting the direct correspondence between the disease and the fund,the rational allocation of the fund under the control of the total amount has been realized.It has aroused the enthusiasm of medical institutions to treat serious and difficult diseases,guaranteed the vital interests of insured personnel,prompted hospitals to actively control and reduce medical expenses,and promoted the transformation of medical insurance handling work from passive to active.Conclusion:The effect is obvious and sustainable since the implementation of weight payment method based on "one weight and two coefficients" as a core content(DW-PS) in Ma'anshan City.The method provides a useful experience for solving the problem of medical insurance payment by referring to the concept of quantitative science.
Purpose:In order to improving the efficiency of medical insurance fund,control unreasonable growth of medical expenses,improve the quality of medical services,reduce the medical expenses of insured personnel,and to make the medical insurance fund run safely.Method:Establish the method of paying for the weight of diseases.Under the total budget of the whole city,calculate the current appropriation amount of each designated medical institution according to the fund number corresponding to the weight value,and distribute and settle the overall hospitalization expenses of each designated medical institution.Result:Since the implementation of the disease weight payment method,by abstracting the direct correspondence between the disease and the fund,the rational allocation of the fund under the control of the total amount has been realized.It has aroused the enthusiasm of medical institutions to treat serious and difficult diseases,guaranteed the vital interests of insured personnel,prompted hospitals to actively control and reduce medical expenses,and promoted the transformation of medical insurance handling work from passive to active.Conclusion:The effect is obvious and sustainable since the implementation of weight payment method based on "one weight and two coefficients" as a core content(DW-PS) in Ma'anshan City.The method provides a useful experience for solving the problem of medical insurance payment by referring to the concept of quantitative science.
引文
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[10]国务院办公厅.国务院办公厅关于推进分级诊疗制度建设的指导意见[Z].国办发[2015]70号,2015-9-8.
[2]人力资源和社会保障部.关于进一步推进医疗保险付费方式改革的意见[Z].人社部发[2011]63号,2011-5-31.
[3]方鹏骞,白雪,陈婷,等.新常态下我国医改关键问题思考[J].中华医院管理杂志,2016(5):321-324.
[4]Folland S,Goodman A C,Stano M.The economics of health and health care[J].Bmj British Medical Journal,1997,306(6889):1358-1359.
[5]Ranyard R,Mchugh S.Defusing the risk of borrowing:The psychology of payment protection insurance decisions[J].Journal of Economic Psychology,2004,25(6):738-748.
[6]Chan Y C L,Ho S J K.THE USE OFBALANCED SCORECARD INCANADIAN HOSPITALS[J].Advances in Management Accounting,2011.
[7]谢文义,沙琳,孔德明,等.平衡计分卡在医保成本控制中的应用[J].重庆医学,2009(1):38-39.
[8]Donaldson C,Magnussen J.DRGs:the road to hospital efficiency[J].Health Policy,1992,21(1):47-64.
[9]刘亚歌,彭明强.医疗保险费用支付方式改革对医院管理的影响[J].中国医院管理,2011,31(7):52-54.
[10]国务院办公厅.国务院办公厅关于推进分级诊疗制度建设的指导意见[Z].国办发[2015]70号,2015-9-8.