广州城镇职工医保住院费用支付对医院效益的影响评价

Influence Evaluation of Urban Employees′Medical Expense Payment in Hospitalization on Hospital Benefit in Guangzhou City

目的评价广州市城镇职工医保住院费用支付对医院效益的影响。方法以广州市15家三甲综合医院为研究对象,基于2002年度实施城镇职工医保以来各主要时段的医保住院费用结算数据,分析医院医保支付标准的影响因素、医保费用支付效果、医保费用超支情况、参保人自费率和自付率变化情况。结果医院医保支付标准主要受该医院住院医疗费用水平、医院规模与医疗服务量的影响,其调整机制由医保部门决定;医院的医保支付效果受支付标准调整影响较大;这15家医院医保费用超支较严重,在2011年及2012年,部分医院的结算单元出现严重超支,个别结算单元超支费用已超过400万元,直接影响其经济效益,而参保人的自费率、自付率有所下降,医院维护了其社会效益。结论医院效益受医保费用支付效果的影响较大,应加快建立健全的支付标准调整机制,完善支付制度;医院可采取医保精益管理等措施提升医保服务效能。

Objective： To assess the influence of urban employees＇ medical expense payment in hospitalization on hospital benefits. Method：The authors made 15 comprehensive hospitals of Class A in Guangzhou City the study subjects, and made the analysis on the influencing factors,effect of medical insurance payment,overrun of medical insurance, self-paying rate of the insured and the changes of co-pay rate. Result ： Standards of medical insurance payment, exerting enormous implications on insurance payment effect,are affected by medical expense ranges, scale and medical service quality of the hospital and its regulatory mechanism is decid- ed by medical insurance department. The overrun of medical insurance in the 15 hospitals is serious. The settlement unit in some hos- pitals is greatly overrun and individual unit overrun 4,000,000 yuan,which affects directly the economic benefits. However, self-pay- ing rate and co-pay rate of the insured reduced, which means that hospitals maintain their social benefits. Conclusion ： Hospital bene- fits are affected greatly by the effect of medical insurance payment so regulatory mechanism for payment standard should be established and improved to perfect payment system. And hospitals should take measures of refined management for medical insurance to improve the efficiency of medical insurance.