基于DRGs的精神专科医院医保费用精细化管理研究

Research on fine management of medical insurance expenses in mental specialized hospitals based on DRGs

在中国人口老龄化日益严重、医疗保险覆盖人口不断扩大的背景下,医疗保险资金压力巨大。国家鼓励各地改进各种支付方式,如按床日数、病人数等多种方式计费。苏州市广济医院作为精神专科医院,精神病院和其他综合医院的门诊量和住院服务能力差异很大,医保费用结算改革也势在必行,引入DRGs进行计费结算。文章阐述了DRGs的具体内容以及实施方式。实施基础主要分为加强人才培养、夯实人才基础、研发DRGs绩效评价平台、加强病案首页管理、建立工作组织体系,构建DRGs监管体系,使用DRGs方法来客观、定量评价医院服务能力、服务绩效和医疗服务质量,逐步提高定量评估方法在医院评估中的比例。从而达到在不影响服务质量的同时控制医保支出费用,医院、病患、医保实现多赢共赢的医疗改革目标。

Under the background of the aging population in China and the expanding population of medical insurance,the pressure on medical insurance funds is huge.The state encourages local governments to improve various payment methods,such as bed-to-bed days and number of patients.As a psychiatric hospital,Suzhou Guangji Hospital has a wide range of outpatient and inpatient services in psychiatric hospitals and other general hospitals.The reform of medical insurance fee settlement is also imperative,and the classification of DRGs is introduced for billing settlement.This article describes the specific content and implementation of DRGs.The implementation basis is mainly divided into strengthening personnel training,consolidating the talent base;developing DRGs performance evaluation platform;strengthening the management of medical records on the home page;and establishing a work organization system.To build a DRGs regulatory system,use the DRGs method to objectively and quantitatively evaluate hospital service capabilities,service performance and medical service quality,and gradually increase the proportion of quantitative assessment methods in hospital evaluation.In order to achieve the medical reform goal of hospitals,patients and medical insurance,the hospital,patients and medical insurance can achieve win-win and win-win results without affecting the quality of service.