总额控制下的病种分值付费和单病种付费支付方式比较

Comparison of the method of paying for the value of the disease under the total amount and the payment method of the single disease

目的分析比较总额控制下的病种分值付费和单病种付费支付方式的应用效果。方法回顾性分析2015年—2018年总额控制下病种分值付费和单病种付费模式下的平均住院费用、医保基金支出以及医保基金收入等基本情况,比对分析总额控制下单病种付费模式下与病种分值付费模式的总体运行效率。结果2015年—2018年总额控制下病种分值付费情况存在轻微波动,但不出现明显上涨现象,稳定于9000元左右的水平,并且总额控制下病种分值付费的医保基金结余率处于17%的水平,同时具有稳定的医保基金支出与医保基金收入水平。相比较总额控制下病种分值付费,单病种付费模式下的平均住院费用更高,且呈现出逐年增加的发展趋势;相比较2015年的平均住院费用,2018年平均住院费用高出500元。2015年—2018年总额控制下单病种付费的医保基金结余率具有较大波动,表示医保基金支出与医保基金收入水平不稳定。结论总额控制下的病种分值付费模式具有明显的医疗费用以及医保基金费用支出控制效果,但同时也具有较大的基础投入水平以及较高管理成本等缺陷端,总额控制下的单病种付费模式具有方便管理的优势,但是在费用控制、病种涵盖等方面不如病种分值付费,总额控制下的单病种付费与病种分值付费各具优势和不足,需要依据区域情况,取长补短,因地制宜以及择优而用,确保健全医保支付方式。

Objective To analyze the application effect of the payment of disease type and the payment of single disease payment under the control of total amount.Methods A retrospective analysis of the basic hospitalization expenses,medical insurance fund expenditures and medical insurance fund income under the control of the total value of the disease and the single-income payment model under the total control from 2015 to 2018 were taken,and to have comparative analysis of the total control of the single disease overall operational efficiency of the payment model with the payment model.Results There was a slight fluctuation in the payment of disease value under the control of total amount from 2015 to 2018,but there was no obvious increase,which was stable at around 9000 yuan,and the balance of medical insurance fund paid for the disease value under the total control was at 17%level and has both stable medical insurance fund expenditure and medical insurance fund income level.Compared with the total score control under the total amount control,the average hospitalization cost under the single disease payment mode was higher,and showed a trend of increasing year by year;compared with the average hospitalization cost in 2015,the average hospitalization cost in 2018 was higher,out of 500 yuan.From 2015 to 2018,the balance of the medical insurance fund paid for the control of the single disease had a large fluctuation,indicating that the medical insurance fund expenditure and the medical insurance fund income level were unstable.Conclusion The disease-based payment model under total control has obvious control effect of medical expenses and medical insurance fund expenses,but it also has a large basic input level and high management cost and other defects.The payment model has the advantage of convenient management,but it is not as good as the cost control and disease coverage,and the single disease payment and the disease value payment under the total control have their own advantages and disadvantages,which need to be based on the regional situation.We need to make use of the strengths and weaknesses,adapt to local conditions and choose the best,to ensure a sound medical insurance payment method.