分解住院费用至门诊问题剖析及监管对策研究

Analysis of the Problem of Decomposing Hospitalization Expenses to Outpatient Services and Research on Supervision Countermeasures

目的:研究探讨医院在参保患者住院期间分解住院费用至门诊问题的监管对策。方法:随机抽选湖南省19家三甲医院,调取2020年HIS系统门诊与住院数据,开展大数据分析。通过案件追溯、人员访谈等方式,剖析25件信访案件发生情形、产生原因、问题性质、结果处理以及相关方感受或意见等。邀请医院院长等相关人员座谈,对问题发生原因、解决思路等进行深入探讨。结果:分解住院问题平均发生率11.3%,次均门诊缴费769.13元,增加了患者跑腿及费用负担。发生原因主要为医院规避医疗费用管控指标考核,也存在漠视群众利益问题。建议:明确问题性质与查处标准,完善医保服务协议,强化医院行风建设,纳入日常智能实时监管等。

Objective:To study and explore the supervision countermeasures of decomposing hospitalization expenses to outpatients during the hospitalization of insured patients.Methods:19 third class hospitals in Hunan were randomly selected,and the outpatient and inpatient data of HIS system in 2020 were transferred to carry out big data analysis.By means of case tracing and personnel interviews,this paper analyzes the occurrence,causes,problem nature,result handling and feelings or opinions of relevant parties of 25 petition cases.The hospital president and other relevant personnel were invited to have a discussion to deeply explore the causes and solutions of the problems.Results:The average incidence of inpatient problems was 11.3%,and the average outpatient payment was¥769.13,which increased the patients'running errands and cost burden.The main reason is that the hospital evades the assessment of medical cost control indicators,and ignores the interests of the masses.Suggestions:Clarify the nature of the problem and investigation standards,improve the medical insurance service agreement,strengthen the construction of hospital style,and incorporate daily intelligent real-time supervision.