医保支付方式改革对新疆某三甲医院的影响及对策

The influence and countermeasure of the reform of medical insurance payment method in a third-class hospital in Xinjiang

目的分析医保支付方式改革对乌鲁木齐某三甲医院的影响,根据结果提出对策建议。方法收集乌鲁木齐某三甲医院2014~2018年医保相关数据,结合访谈法对结果进行分析。结果新疆实行控总额、控均费为主导的,按病种付费为主的复合付费方式。然而,按病种付费的推行进度较缓慢。该院2014~2018年就诊人数逐年增多,医保患者各年度次均住院和门诊费用比较,差异有高度统计学意义(P<0.01)。该院城镇职工医保患者就诊次均费用水平整体高于城镇/城乡居民医保患者。此外,2014~2018年新疆基本医保统筹支付比例略有提升,但不同医保类型之间尚有较大差距。结论该院近年来就诊人数逐年增加,次均医疗费用控制工作完成较好。但目前仍以按项目付费为主要收费方式,按病种付费推行进度较缓慢。新疆现阶段医保支付方式改革缺乏具体措施以及有效的监督手段,可能会导致院方在执行过程中积极性不高。院方应从自身做起,积极探索按病种付费的实际执行办法,如调整临床路径,降低医疗成本,做好控费工作,提高医保信息化程度,将改革政策真正贯彻落实。

Objective To analyze the impact of the reform of medical insurance payment methods on a third-class hospital in Urumqi,and to propose countermeasures based on the results.Methods The medical insurance related data of a third-class hospital in Urumqi from 2014 to 2018 were collected.While combined the interview method,the results were analyzed.Results Xinjiang implements a compound payment method that was dominated by the total amount of control and the average amount of control.However,the implementation of payment by disease was slow.The number of hospital visits in the hospital from 2014 to 2018 were increased year by year.Compared the medical insurance patients'annual hospitalization and outpatient expenses,the differences were highly statistically significant(P<0.01).The average cost of medical service visits of urban employees of the hospital was higher than that of urban/urban and rural residents.In addition,from 2014 to 2018,Xinjiang′s basic medical insurance overall payment ratio was increased slightly,but there was still a large gap between different types of medical insurance.Conclusion In recent years,the hospital′s number of doctors has increased year by year,and the second-time average medical cost control work has been completed well.However,payment by project is still the main charging method,and the implementation of payment by disease is slow.The lack of specific measures and effective monitoring methods in the current reform of the medical insurance payment method in Xinjiang may result in the hospital's enthusiasm in the implementation process.The hospital should start from its own,and actively explore practical implementation methods for payment by disease,such as adjusting clinical pathways,reducing medical costs,doing a good job in fee control,improving the degree of medical insurance information,and truly implementing the reform policy.