DRG付费模式下医保基金监管指标阈值设计

Threshold Design of Medical Insurance Fund Regulatory Indicators under DRG Payment

目的:通过科学设计DRG付费模式下医保基金监管指标阈值边界及其测量策略,对医疗机构和医保运行可能存在的问题进行识别,有助于实现全流程、全周期的医保基金智能监测,提升医保基金使用效能。方法:根据科学设定、精准识别、分类分层的设计理念,基于全国部分DRG试点城市运行数据模拟结果,确定指标阈值边界类型和测算方法。结果:根据内涵及导向将监管指标阈值边界划分为上界、下界、上下界,并基于政策需求、专家判断和统计原理构建DRG付费模式下医保基金监管指标阈值设计思路。结论:政策阈值应与改革目标同步并动态调整,不断完善统计阈值测算方法,提升识别精度和效率,阈值风险识别技术置入智能监管平台,强化人工审核。

Objective:Through the scientific design of the threshold boundary of medical insurance fund regulatory indicators and its measurement strategy under the DRG payment,the possible problems in medical institutions and medical insurance operations can help realize the intelligent monitoring of medical insurance funds throughout the process and cycle,and improve the efficacy of medical insurance funds.Methods:According to the design concept of scientific setting,precise identification,and classification and stratification,the threshold boundary type and calculation method of the indicators are determinedbased on the simulation results of the operation data of some DRG pilot cities across the country.Results:The threshold boundaries of regulatory indicators are divided into upper,lower and upper and lower boundaries according to the connotation and orientation,and the design ideas of regulatory indicator thresholds for health insurance funds under the DRG payment model are constructed based on policy needs,expert judgment and statistical principles.Conclusion:The policy threshold should be synchronized with the reform goals and dynamically adjusted,and the statistical threshold calculation method should be continuously improved to improve the accuracy and efficiency of identification.Threshold risk identification technology should be embedded in the intelligent supervision platform,and manual review should be strengthened.