探讨基本医疗保险制度下的病种费用控制

To explore the payment control of disease under basic medical insurance system

探讨基本医疗保险制度下的病种费用控制办法。方法:对病种费用结算标准与随机抽取的样本病例进行费用比较分析,同时对胆囊摘除术(腹腔镜)进行了成本——费用分析。结果:样本实际费用比标准费用高,其中药品费和手术材料费在超支费用构成中占到总超支费用的42%￣84%。胆囊摘除术(腹腔镜)的成本高于医保标准支付费用。讨论:医方应加强药品材料的管控,同时对医保病种实行临床路径管理。保方应注意单病种选择的合理性及病种费用制定的适宜性。

This article discuses method of payment control of disease under basic medical insurance system. The author compares and analyzes the standard accounting payment of a disease with a sample case and analyses the cost/payment of a cholelithotomy operation under peritoneoscope. The result shows the fee paid by patient is higher than the standard charge, and the drugs fee and operation materials fee occupy 42%-84% of the total overspend. The cost of cholelithotomy operation under peritoneoscope is higher than that of standard medical insurance payment. This article also puts forward that hospital should strengthen management and control of drugs and medical materials and supervise the treatment process of medical insurance case, and insurance company should select mono-case insured reasonably and determine disease cost appropriately as well.