按病种付费改革效应的研究--基于对慢粒疾病分组平均费用的分析

Research on Reform Effect of Paying Standard According to Types of Diseases——Based on Average Cost of CM Groups

按病种付费是当前推进医疗体制改革的重要举措之一。本研究以慢粒疾病为例考察按病种付费的可行性并探究其对医疗机构管理带来的可能影响。采用回顾性数据分析法及病历调查法研究了中国医学科学院血液病医院2011-2015年的慢粒髓细胞白血病门诊及住院病历数据,依据相关病例的特征,得出该疾病的10组平均费用。研究发现回顾性数据平均费用可作为医保支付的预算及考核,不能直接作为患者的支付价格。简单的平均费用数值不能反映复杂的疾病发生特性,也与临床推行的规范诊疗路径要求相违背,不易让临床医生接受。易出现患者入组率低和拒收重症患者的副作用,需要建立更合理的病种定价方法,以期解决医保支付问题的同时有助于医疗质量管理。

One of the vital measures promoting medical system reform is to fix the medical cost by classifying different diseases into multiple categories. This article, taking CML as an example, reviews the feasibility of such measure and studies the possible impact it may have on a management level. According to the characteristics of related diseases, the average costs of 10 CML groups are drawn by combining two case study measures, retrospective data analysis and case history study on the outpatients and inpatients of CML in Blood Diseases Hospital attached to Chinese Academy of Medical Science from 2011 to 2015. Study shows that the average retrospective data costs could be used as the budget and assessment of the coverage of social medical insurance, but not a payment price for patients directly.A simple average cost cannot reflect the characteristics of such complex diseases, and it also goes against the clinical standardized path for diagnosis and treatment, which made it unacceptable for clinics. This may result in the side effects such as a low incorporation rate and the rejecting severe patients. A more rational pricing system is needed to be established to resolve the problem of social medical insurance coverage while be beneficial to the medical quality management simultaneously.