医保支付方式按病种分值付费研究进展

Research progress of medical insurance payment method based on Diagnosis-Intervention Packet

目的:梳理分析国内医保基于大数据的病种分值付费(DIP)改革研究与实施现状、对医保患三方利益主体的影响情况以及现存问题,为进一步完善与推广按病种分值付费方式提供思路。方法:计算机检索Web of Science、PubMed、中国知网、万方和维普数据库中DIP付费方式相关研究,对文献进行分析。结果:按病种分值付费作为本土特色的原创医保支付方式,目前研究仍处于探索阶段,国内发文数量逐年递增,国外则聚焦于按疾病诊断相关分组付费(DRG)研究。此外,国内先行地区在DIP实际付费中积累了一定经验,但DIP对医保患三方都带来一定利弊影响,有待在实践中进一步完善与发展。结论:加强学科建设,扩大国际影响力;健全按病种分值付费机制,进一步完善细分病种标准;实地调研评估各地DIP运行情况,初步探索总结DIP付费实践经验;借鉴地方经验,探索中西医协同发展道路;推行全面预算管理,践行事前、事中和事后审核理念等。

Objective:Sort out and analyze the payment mode of medical insurance in China about the research and implementation status of the Big Data Diagnosis-Intervention Packet(DIP)reform,the impact on the three stakeholders of medical insurance patients and the existing problems,so as to provide ideas for further improving the DIP payment method.Methods:The relevant research literature on DIP payment method in Web of Science,PubMed,China National Knowledge Infrastructure(CNKI),Wanfang database,Weipu database were searched and analyzed by computer retrieval.Results:As an original medical insurance payment method with Chinese local characteristics,the research is still in the exploratory stage,and the number of domestic documents is increasing year by year,while foreign countries focus on Diagnosis Related Groups payment research.Besides,the domestic leading regions have accumulated some experience in the actual payment of DIP,but DIP has brought certain advantages and disadvantages to the three parties of medical institutes,medical insurance administrative agencies and patients,which need to be further improved and developed in practice.Conclusions:This paper summarizes the practical progress of the reform of DIP payment mode in China,and puts forward some suggestions:strengthen discipline construction and expand international influence:improve the DIP payment mechanism,and further improve the criteria for subdividing diseases;conduct on-the-spot investigation and evaluation on the operation of DIP in various places,and preliminarily explore and summarize the practical experience of DIP payment;learn from local experience and explore the path of coordinated development of traditional Chinese and western medicine;carry out comprehensive budget management and practice the concept of pre,in and post audit.