“双通道”模式下不同支付方式对医保预算的影响分析:以耐受药肺结核治疗为例

Budget Impact Analysis of Different Payment Methods on the Medical Insurance under the “Dual-Channel” Mode Taking the Treatment of Multi-drug Resistant Tuberculosis as an Example

目的:以耐多药肺结核治疗为例,预测“双通道”模式下不同支付方式对医保基金预算和患者负担的影响,并为该模式在地方层面的落地方式提供参考。方法:基于医保支付方视角构建预算影响分析模型,对照考虑单行支付、门诊参照住院两种支付方式,计算7种治疗方案在住院、门诊中可能产生的报销费用,预测2022—2024年江苏省医保基金支出与患者负担的变化情况。结果:单行支付模式下,江苏省耐多药肺结核患者预计医保支出增额分别为779万、787万和795万,患者人均负担降低17 800~25 200元;门诊参照住院模式下,各年医保支出增额分别为1 208万、1 219万和1 230万,患者人均负担降低27 600~39 100元。结论:“双通道”管理政策的各支付方式在不同程度上增加了医保支出,减轻了患者负担。下一步可探索不同支付方式之间的可替代性,实现基金可持续与患者获益的平衡。

Objective:Taking multidrug-resistant tuberculosis as an example, it is estimated that the impact of different payment methods on the budget of medical insurance fund and the burden of patients under the “dual-channel” mode is predicted, and it provides a reference for the landing method of the model at the local level.Methods:Based on the perspective of the medical insurance payer, the budget impact analysis model was constructed. The possible reimbursement expenses of 7 treatment schemes in inpatient and outpatient clinics were calculated by considering the single-line payment and outpatient as references to the two payment methods, and the change of the expenditure and patient burden of the medical insurance fund in Jiangsu Province from 2022 to 2024 was predicted.Results:Under the one-line payment model, the estimated increases in medical insurance expenditure for patients with multidrug-resistant tuberculosis in Jiangsu Province were 7.79 million, 7.87 million and 7.95 million, respectively, and the per capita burden of patients decreased by 17 800-25 200 yuan.Conclusion:The payment methods of the “dual-channel” management policy have increased the cost of health insurance to varying degrees and reduced the burden on patients. The next step is to explore alternatives between different payment methods and to achieve a balance between the sustainability of the fund and the benefits to patients.