芜湖市区域总额预算下按病种分值付费效果评价

Evaluation on Effect of Diagnosis-intervention Packet Under the Regional Total Budget of Wuhu

目的:评估芜湖市区域总额预算下按病种分值付费实施效果,为优化制度设计提供参考依据。方法:聚焦实施效果,围绕分值付费预算总额、医保基金安全性、住院服务流向及政策实施进展4个维度进行评估。结果:2015-2019年,分值付费年度预算占职工医保筹资总额比例由50.4%下降到45.7%;职工医保基金年度实际支出占筹资总额比例在67.5%-79.0%之间,市域内医疗卫生机构占职工医保实际支出比例保持在较高水平(84.8%-89.6%);职工医保年住院率由18.4%下降到15.7%,市域内住院比例保持在90%以上;市域内住院按病种分值付费结算例数保持在98%左右。结论:芜湖市按病种分值付费年度预算总额较为合理,职工医保基金保持较好安全性,参保对象年住院率呈下降趋势,按病种分值付费已成为主要结算方式。应进一步优化病种组合,建立病种分值动态调整机制,对常见住院病种实施“同病种同保障待遇”,结合机构系数调整,引导合理就诊,体现价值导向。

Objective:To evaluate the implementation effect of diagnosis-intervention packet(DIP)based on the regional total budget of Wuhu,so as to provide references for optimizing the system design.Methods:Focusing on the implementation effect,the evaluation was carried out from four dimensions including the total budget of DIP,the security of medical insurance fund,the flow of inpatient services and the progress of policy implementation.Results:From 2015 to 2019,the proportion of the annual budget of DIP in the total financing of employees'medical insurance decreased from 50.4% to 45.7%.Meanwhile,the annual actual expenditure of employees'medical insurance fund accounted for 67.5%to 79.0% of the total amount of financing.The proportion of medical and health institutions in the city in the actual medical insurance expenditure of employees remained at a high level(84.8%-89.6%).However,the annual hospitalization rate of employees'medical insurance decreased from 18.4% to 15.7%,and the proportion of hospitalization in the city remained above 90%.Finally,the number of cases of hospitalization in the city which were settled by DIP was kept at about 98%.Conclusion:The total annual budget of DIP of Wuhu is relatively reasonable,the employees'medical insurance fund maintains the safety,the annual hospitalization rate of insured people has been decreasing and the DIP has become the main settlement method.Therefore,groups of diseases should be further optimized,and the dynamic adjustment mechanism should also be established.The measures of"the same disease and the same guarantee treatment"on the common inpatient diseases should be carried out combined with the adjustment of institutional coefficient,so as to guide the reasonable medical treatment and reflect the value orientation.