基于医保支付标准的医疗机构合理诊疗行为研究

Research on Rational Diagnosis and Treatment Behavior of Medical Institutions Based on Medical Insurance Payment Standard

目的:分析医院超医保支付限定项目分布情况和超限定原因,为促进医院合理诊疗和精细化管理提供依据。方法:收集某肿瘤专科医院2020年—2021年超医保支付限定项目,采用分类和对比分析方法,对超限定数量和金额进行分析。结果:将医院超医保支付限定项目分为抗肿瘤药物、辅助类药物、手术、检查检验、呼吸支持、静脉注射6大类,其中抗肿瘤药物和辅助类药物超限定数量之和占总超限定数量的99.24%,抗肿瘤药物和辅助类药物超限定金额总和占总超限定金额的99.45%。辅助类药物的超限定数量和金额(分别为30410个和1134342.95元)高于抗肿瘤药物的数量和金额(分别为4396个和341061.85元)。结论:药物超医保限定数量和金额占比较高,药物作为超医保支付限定的主要内容,其原因可能跟医保政策要求与医生的判定标准存在差异有关,定点医疗机构可通过开展院内“医保-医疗-医药”的多学科合作加强政策培训、建立前置审核系统、加强医院和医保管理部门之间的沟通等方式,强化药物合理使用管理,规范诊疗行为。

Objective:The paper analyzes the distribution of hospitals'items beyond basic medical insurance payment limit and the reasons,providing a basis for promoting hospitals'rational diagnosis and treatment as well as refined management.Methods:The study collected the items beyond basic medical insurance payment limit of a specialized oncology hospital from 2020 to 2021,and analyzed the number and amount of items with methods of classification and comparative analysis.Results:The hospitals'items beyond basic medical insurance payment limit were classified into 6 major categories,including anti-tumor drugs,adjuvant drugs,surgery,examination and test,respiratory support,and intravenous injection.The number and amount of anti-tumor drugs and adjuvant drugs accounted for 99.24%and 99.45%of the number and amount of total items.The number and amount of adjuvant drugs(30410 and$1134342.95,respectively)was higher than anti-tumor drugs(4396 and$341061.85,respectively).Conclusion:The proportion of number and amount of drug items was relatively high,which may be related to inconsistency between requirements of medical insurance policy and doctors'judgment standards.Designated hospitals for healthcare security can strengthen rational use and management of drugs,and standardize diagnosis and treatment by interdisciplinary cooperation of medical insurance,hospital and drugs within the hospital to strengthen policy training,establishing a pre-audit system,and strengthening communication between hospitals and medical insurance departments.