综合评价某三甲医院不同医保支付方式下的医保管理成效

Comprehensive evaluation on the effect of medical insurance management based on different medical insurance payment methods in a class one grade a hospital

目的分析某院在三种不同医保支付方式下的医保管理成效变化,为综合评价医保管理成效提供思路,为某院后续医保管理的工作重点阐明方向。方法以某三甲综合医院2016-2018年间74 108例享受广州市基本医疗保险待遇的出院患者为研究对象,提取10项可反映医院医保管理成效的指标,根据当地医保局推行的三种不同医保支付方式顺序划分为3组,分别对其进行描述性分析及使用主成分分析法进行综合评价。结果次均住院费用、平均住院时间逐步下降,记账率、CMI值、三四级手术比例逐步提升。主成分分析共抽取2项主成分,两者的累积贡献率为100%。按病种分值付费支付方式的综合得分为1. 923,按病种付费支付方式的综合得分为-0. 007,总额控制下的平均费用定额结算支付方式综合得分为-1. 916。结论某院按病种分值付费下的医保管理综合成效最佳,其医保管理后续的工作重点应对患者材料费及检查化验费加强管控。主成分分析法可为综合评价医院医保管理综合成效提供思路。

Objective Objective To analyze the effect of Medical Insurance Management( MIM) of the hospital based on different medical insurance payment methods,to provide ideas for comprehensive evaluation on the effect of MIM,and to clarify the focus of MIM for the hospital in the future. Methods A total of 74 108 discharged patients from 2016 to2018 in a major public hospital who benefited from Guangzhou basic medical insurance were divided into three groups according to the order of three different medical insurance payment methods advocated by the local medical insurance bureau. And10 indicators of the effect of MIM were chosen. Descriptive analysis was employed to describe the indicators and principal component analysis was adopted for comprehensive evaluation. Results Both the average hospitalization costs and the average hospital stays decreased gradually. However,the medical insurance reimbursement ratio,CMI and the proportion of thirdand-fourth-class operations increased gradually. The cumulative contribution rate of the two principal components selected in principal component analysis was 100%. The comprehensive score of payment by disease scoring was 1. 923 while that of payment by diagnosis related groups was-0. 007. Besides,the comprehensive score of payment by average fee settlement under total budget was-1. 916. Conclusion The best comprehensive effect of MIM in the hospital is linked to payment by disease scoring and the focus of MIM for the hospital in the future is to control the costs of medical materials,examination and test more tightly. Moreover,principal component analysis can provide ideas for comprehensive evaluation on MIM.