DIP改革下医疗机构医保管理策略研究——以海南省某三甲医院为例

Research on Medical Insurance Management Strategy of Medical Institutions Under the DIP Reform——Taking a First-class Hospital in Hainan Province as an Example

按病种分值付费(DIP)是基于一般均衡及大数据原理,在医保支付方式改革领域的创新应用。随着DIP改革进入实际付费阶段,公立医院采取何种措施应对改革带来的不确定性、获取合理医保支付,是值得研究的问题。本研究通过调查问卷等方式对海南省某公立医院实施DIP后的应对策略展开分析,发现通过临床路径管理、病案首页质控及单病种支付标准费用管理等手段,能够有效提升病种入组率、获得合理医保资金。结果表明,在医保支付方式改革背景下,医疗机构要夯实信息化基础,通过规范病案质控、临床路径管理及单病种费用管理,根据功能定位发展优势学科,以适应变革,稳步推动医院高质量发展。

Diagnosis-Intervention Packet(DIP)is an innovative application in the field of medical insurance payment reform based on general equilibrium and principles of big data.As the DIP reform enters the stage of actual payment,it is worth studying what measures public hospitals should take to deal with the uncertainty brought about by the reform and obtain reasonable medical insurance payment.This study carried out analysis of hospital's coping strategies after the implementation of DIP in a public hospital in Hainan Province through questionnaires and other methods.The study found that the public hospital effectively increased the grouping rate of diseases and obtained reasonable medical insurance funds by means of clinical pathway management,the first page of medical record quality control,and single-disease payment standard management.The research results show that under the reform of medical insurance payment methods,medical institutions should consolidate the foundation of informatization through standardizing the quality control of medical records,clinical path management and single disease cost management.Meanwhile,they should develop advantageous disciplines according to functional positioning,adapt to changes and steadily promote high-quality development of hospitals.