按病种分值付费下三级公立医院实体肿瘤专业病种收治结构与医疗费用负担研究

Study on the treatment structure and burden of medical expenses of solid tumor diseases in tertiary public hospitals under diagnosis-intervention packe payment

目的分析三级医院实体肿瘤专业病种收治结构与医疗费用负担,为按病种分值(DIP)付费下三级医疗机构优化病种结构,控制医疗费用,促进医院医保收支平衡等提供参考依据。方法采用典型抽样在内蒙古自治区赤峰市内抽取3家三级医疗机构(赤峰市医院、赤峰学院附属医院、赤峰市肿瘤医院)作为样本医院,收集各样本医院2021年11月至2022年4月收治的实体肿瘤患者的DIP付费数据、医保报销数据与医疗费用数据。根据RW与次均医疗费用指标,划分为优势病种、潜在病种、基础病种、劣势病种4类,对病种收治结构和医疗费用负担进行分析。结果共收集实体肿瘤患者13946例次,依据主诊断与手术操作数据入至387个DIP实体肿瘤病种,优势病种142个,潜在病种43个,基础病种109个,劣势病种93个。医院优势病种每百元医疗费用盈余14.01元,潜在病种每百元医疗费用亏损13.28元,基础病种每百元医疗费用盈余7.96元,劣势病种每百元医疗费用亏损7.91元。结论DIP付费下,三级医疗机构应以DIP病种数据为导向,精准施策,纵深优化病种收治结构。基于DIP病种开展精细化医疗费用控制工作,降低患者医疗费用负担,维护医院医保收支平衡,从而促进医保支付方式改革中医、保、患三方共赢。

Objective To provide a reference basis for optimizing the disease structure,controlling medical expenses,and promoting the balance of medical insurance under diagnosis-intervention packe(DIP)payment by analyzing the treatment structure and burden of medical expenses of solid tumor diseases in tertiary hospitals.Methods Three tertiary medical institutions(Chifeng Municipal Hospital,Affiliated Hospital of Chifeng University,Chifeng Tumor Hospital)were sampled from Chifeng City of Inner Mongolia Autonomous Region by using typical sampling as sample hospitals.The DIP payment data,medical insurance reimbursement data,and medical expense data of solid tumor patients hospitalized by each sample hospital from November 2021 to April 2022 were collected.According to the RW and sub-average medical expenses indicators,it was divided into four categories:dominant disease,potential disease,basic disease,and inferior disease.Disease admission structure and medical expenses burden were analyzed.Results A total of 13946 solid tumor patients were collected.Three hundred and eighty-seven DIP solid tumor diseases were entered according to the main diagnosis and surgical operation data.Among them,there were 142 dominant diseases,43 potential diseases,109 basic diseases,and 93 inferior diseases.The dominant disease of hospital had a surplus of 14.01 yuan per 100 yuan of medical expenses.Potential disease had a loss of 13.28 yuan per 100 yuan of medical expenses.Basic disease had a surplus of 7.96 yuan per 100 yuan of medical expenses.Inferior disease had a loss of 7.91 yuan per 100 yuan of medical expenses.Conclusion Under DIP payment,tertiary medical institutions should be guided by DIP disease data,implement precise policies,and optimize the admission structure of disease types in depth.Based on DIP disease types,carry out refined medical cost control work,reduce the burden of patients’medical expenses,and maintain the balance of hospital medical insurance revenue and expenditure,so as to promote the reform of medical insurance payment methods and achieve a win-win situation for medicine,insurance and patients.