我国基本医疗保险总额控制下的按病种分值付费现状研究

Study on Status Quo of Disease-Based Score Payment Under the Global Budget Control in Basic Medical Insurance of China

为提高医保基金的使用效率,控制医保费用的不合理增长,我国淮安市、中山市等地区开始试行总额控制下的按病种分值付费。按病种分值付费的主要流程是:对病种进行分类——确定病种分值——设定调整系数——费用结算。按病种分值付费尚存在病种分类方法不尽合理、病种分值测算的科学性有待提高、调整系数的设置不能充分反映成本差异等问题,建议在进行按病种分值付费方案设计时,加强方案设计的科学性和可行性,注重方案设计与分级诊疗的衔接性。

In order to improve the efficiency of using health insurance funds, and control the unreasonable growth of medical insurance expenses, the Disease-Based Score Payment under the Global Budget Control in Basic Medical Insurance had been carried out in some regions of China such as Huainan and Zhongshan. For the better understanding of this payment system, the following aspects were analyzed in this paper： the theoretical connotation of Disease-Based Score Payment and the main process of the design. The main process included the classification of disea- ses, the determination of disease scores, the setting adjustment coefficient and the expense settlement. This paper pointed out that the method for the classification of diseases was not reasonable, the scientific nature of the measurement of the disease＇ s needed to be improved, and the setting of the adjustment coefficient could not fully reflect the cost difference. Finally, some advices were put forward： strengthen the scientific and feasi- bility of the program design, increase the connection between the program design and the grading treatment.