总额预付下门诊特病医保费用实证分析

Empirical Analysis of Outpatient Medical Insurance Costs under Total Prepayment

目的:了解医保门诊特病费用特征,探讨门诊特病管理改进策略。方法:收集重庆某大型三甲综合医院2017—2018年医保患者门诊特病费用,运用数据透视表功能进行描述性统计分析。结果:职工医保门诊特病消耗较多费用资源,且慢性病消耗大部分特病门诊医疗资源;基金消耗过于集中部分病种,横向公平性受损,现行的医保支付方式不利于费用控制。结论:严格特病准入、退出机制;引导慢性病患者基层就诊;探索按病种限额支付方式,通过延伸医保智能审核,前置审核规则,让事后监管变事前、事中服务的方式,规范医疗服务行为,促进医保基金安全合理使用。

Objective To understand the cost characteristics of outpatient diseases in medical insurance,and to explore strategies for improving outpatient diseases management.Methods The cost of outpatients with special medical insurance for a IIIA hospital in Chongqing from 2017 to 2018 was collected and a descriptive statistical analysis was performed using the pivot table function.Results Staff medical insurance outpatients consumed many resources and chronic diseases consumed the most of medical resources for outpatients.Certain diseases consumed too much of the fund and the horizontal equity was impaired,and the current medical insurance payment methods were not conducive to cost control.Conclusion We should apply strict admission and withdrawal mechanism of special diseases,guide patients with chronic diseases to take medical care at primary level,explore the payment method based on the disease limit,extend the medical insurance smart audit and pre-examination rules to allow ex-post supervision to change the service before and during the event,and regulate medical service behavior to promote the safe and rational use of medical insurance funds.