城市职工医疗保险按病种分值付费的影响因素分析

Analysis of Influencing Factors of Urban Employee Medical Insurance Payment by Disease Points

目的探讨城市居民医疗保险按病种分值付费的影响因素。方法所有入组病例均通过数字随机法选择2021年1月—2022年1月期间在该院住院的200例职工医疗保险参保患者,针对入组者性别、年龄(60岁为标准)、是否存在药物过敏史、入院途径(门诊/急诊)、住院天数(院平均住院天数为标准)、是否纳入临床路径、是否接受手术治疗、诊断疾病数量(3个为标准)以及是否需要抢救等情况进行单因素与多因素Logistic回归分析。结果年龄>60岁,住院天数在院平均住院天数以外,未纳入临床路径,未接受手术治疗以及住院期间需要抢救治疗等均为影响按病种分值付费结算的相关及独立危险因素。结论对于年龄>60岁,住院天数在院平均住院天数以外,未纳入临床路径,未接受手术治疗且住院期间需要抢救治疗者,其出现按病种分值付费结算超标的可能性较大。

Objective To explore the influencing factors of urban residents'medical insurance payment according to the disease category.Methods All the enrolled cases selected 200 employees medical insurance insured patients who were hospitalized in the hospital from January 2021 to January 2022 by digital random method.Univariate and multivariate Logistic regression analysis was performed on the gender,age(60 years old as the standard),whether there is a history of drug allergy,and admission route(outpatient/emergency),the number of days of hospitalization(average hospitalization days in the hospital as the standard),whether to be included in the clinical pathway,whether to accept surgical treatment,the number of diagnosed diseases(3 as the standard),and whether to require rescue.Results Age over 60 years old,days of hospitalization other than the average length of stay in hospital,not included in clinical pathway,not receiving surgical treatment,and needing rescue treatment during hospitalization were all related and independent risk factors affecting the settlement of payment by disease points.Conclusion For people over 60 years old,the number of hospitalization days in the hospital is not included in the clinical pathway,and the patients who have not received surgical treatment and need rescue treatment during hospitalization are more likely to exceed the standard of payment and settlement according to the disease type.