国家医保药品谈判对住院费用及医保支付的影响

Influence of medicines covered under national medical insurance system’s price negotiation program on hospitalization expenses and medical insurance payment

[目的]分析国家医保药品谈判政策对四川省某三甲医院患者住院费用、费用结构及医保支付方式改革的影响,为医保、卫生行政部门、医疗机构及卫生监管机构的管理决策提供参考依据。[方法]基于四川省某三甲医院2014-2021年住院患者结算数据,采用描述性统计分析、单因素分析、多因素分析等方法分析医保药品谈判对患者住院费用和医保支付方式改革的影响。[结果]政策实施前(2014-2017年)住院患者74.9万人次(年均18.725万人次),年均增长率为5.4%,年次均住院费用为21,221.49元,药占比为24.1%;政策实施后(2018-2021年)住院患者89.1万人次(年均22.275万人次),年均增长率为2.47%,年次均住院费用为24,481.11元,药占比为18.2%。政策实施后除中西医结合科和肿瘤科平均住院费用有所下降外,其他科室年次均住院费用均呈上升趋势。按病组分值付费的患者未使用、使用1种、使用2种及以上国谈高价药品的年次均住院费用分别为8127.87元、14,077.25元和20,814.68元,次均支付盈亏金额分别为727.21元、697.98元和602.5元;DRG点数付费的患者未使用、使用1种、使用2种及以上国谈高价药品的年次均住院费用分别为7507.7元、13,195.17元和20,007.9元,次均支付盈亏金额分别为2055.64元、1517.51元和-727.27元。[结论]政策实施后住院患者人次稳步增加,患者住院费用持续快速增长,各医疗科室受影响的情况有较大差异,患者使用国谈高价药品的数量影响住院费用和医保支付方式改革。

Objective To analyze the influence of medicines covered under national medical insurance system’s price negotiation program on the hospitalization expenses, cost structure and medical insurance payment reform of a 3A public hospital in Sichuan Province, and to provide reference for the management decision of healthcare security administration, medical institutions and health supervision agencies.Methods Based on the settlement data of the hospitalization in a 3A public hospital in Sichuan Province from 2014 to 2021,descriptive statistical analysis, univariate analysis, multivariate analysis and other methods were used to analyze the impact of medicines covered under national medical insurance system’s price negotiation program on the hospitalization expenses and medical insurance payment reform.Results Before the implementation of the policy(2014-2017),there were 749,000 hospitalized patients(187,250 patients annual average),with an average annual growth rate of 5.4%. The average annual hospitalization cost was 21,221.49 yuan, and the proportion of drugs was 24.1%. After the implementation of the policy, there were 891,000 hospitalized patients(222,750 patients annual average),with an average annual growth rate of 2.47%. The average annual hospitalization cost was 24,481.11 yuan, and the proportion of drugs was 18.2%. After the implementation of the policy, apart from the department of integrated Chinese and western medicine and the department of oncology, which showed a downward trend in average hospitalization cost, the average annual hospitalization cost of other departments showed an upward trend. The average annual hospitalization cost of patients who did not use, used one, two or more negotiated high-priced medicines with diagnosis-intervention packet(DIP)were 8,127.87,14,077.25 and 20,814.68 yuan respectively. The average amount of profit and loss was 727.21,697.98 and 602.5 yuan respectively. The average annual hospitalization cost of patients who did not use, used one, two or more negotiated high-priced medicines with diagnosis related groups(DRG)were 7507.7,13,195.17 and 20,007.9 yuan respectively. The average amount of profit and loss was 2055.64,1517.51 and-727.27 yuan respectively.Conclusions After the implementation of the policy, the number of hospitalized patients has increased steadily, and the hospitalization expenses have continued to increase rapidly. The impacts for different medical departments vary from each other. The number of negotiated high-priced medicines used by patients affects the hospitalization expenses and the reform of medical insurance payment.