按病种分值结算 加强医保精细化管理——以江门市某三甲医院为例

Practice of strengthening fine management of medical insurance in hospitals based on the score of diseases--a case study of a class a tertiary hospital in jiangmen city

在按病种分值结算付费方式改革下,广东省江门市某三甲医院收治疑难危重患者数有所增加、开展临床路径数增加、住院患者药占比有所下降,主要医疗服务指标逐步呈现良好趋势,但也存在病种分值库不完善、危重患者结算方式不合理等问题。该院通过完善医保管理工作体系,开展医保政策宣传和培训,完善医保管理信息化建设,加强病案首页管理和病种费用监控,完善病种分值库和编码库,调整收治患者病种结构等措施,逐步适应按病种分值付费方式的发展,努力实现医、保、患三方共赢。

Under the reform of settlement and payment by disease score,the number of complicated and seriously-ill patients,the number of clinical pathway and the proportion of inpatients in a Class A tertiary hospital in Jiangmen City increased,and the main medical service indicators gradually showed a good trend.However,there are still some problems such as incomplete disease score database and unreasonable settlement method for seriously-ill patients.By improving the medical insurance management system,carrying out publicity and training of medical insurance policies,improving the information construction of medical insurance management,strengthening the management of the front page of medical records and the monitoring of disease cost,improving the disease score database and coding database,adjusting the structure of the disease types of patients,the hospital gradually adapts to the development of the payment by disease score,and strives to achieve a win-win situation for the three parties.