云南省临沧市M县医疗卫生共同体改革对医保基金支出的影响研究

Study on the impact of county medical community reform on the medical insurance fund expenditure in M county,Lincang city of Yunnan province

目的评估县域医疗卫生共同体(以下简称医共体)改革后医保基金支出的变化,为深化医共体改革和加强医保基金管理提供参考。方法收集云南省临沧市M县2016年至2019年的城乡居民医疗保险数据,采用基于间断时间序列的分段回归模型分析医共体改革前后该县医保基金支出的变化情况。结果改革后县级医院出院人数呈下降趋势,平均每月减少25.996人;次均住院费用、次均住院统筹基金支出和次均门诊统筹基金支出均呈上升趋势,分别平均每月增加90.931元、50.014元和1.528元。乡镇卫生院次均住院费用、次均住院统筹基金支出和次均门诊统筹基金支出改革后均呈上升趋势,分别平均每月增加31.191元、38.678元和0.085元。医共体外医保基金流向呈持续上升趋势,改革后次均住院统筹基金支出平均每月增长33.005元,次均门诊统筹基金支出平均每月增加4.896元。结论M县医共体改革后医保基金支出仍需进一步管控,应强化顶层设计和龙头医院引领作用,探索医保总额打包付费支付方式改革,完善区域信息化平台,规范双向转诊制度和加强监管等。

Objective To evaluate the impact of the reform of the county medical community on the expenditure of medical insurance funds,and to provide references for maintaining the stability of the medical insurance fund and deepening the reform of the medical community.Methods Medical insurance data of urban and rural residents in M County,Yunnan province from 2016 to 2019 were collected,and a discontinuous time series model was used to analyze the impact of county medical community reform on medical insurance fund expenditures.Results Since the reform,the number of patients discharged from county-level hospitals has shown a downward trend,averaging a decrease of 25.996 people per month;yet increases have emerged with the average hospitalization expenditure,the average hospitalization overall fund expenditure,and the average outpatient overall fund expenditure,averaging a monthly increase of 90.931 yuan,50.014 yuan and 1.528 yuan respectively.The average hospitalization expenditure,the average hospitalization overall fund expenditure,and the average outpatient overall fund expenditure of the township hospitals all showed an upward trend,averaging a monthly increase of 31.191 yuan,38.678 yuan and 0.085 yuan respectively.The flow of external medical insurance funds of the medical community has shown a continuous upward trend,averaging a monthly increase of hospitalization fund expenditures of 33.005 yuan,and a monthly increase of outpatient overall fund expenditures of 4.896 yuan overall.Conclusions The M County medical community should further strengthen the top-level design,explore the reform of medical insurance payment methods,improve the regional information platform,standardize the referral system,and strengthen supervision to deepen the construction of the medical community to ensure the sustainable operation of medical insurance funds.