DRG收付费一体化改革影响机制分析——以福建省泉州市和三明市为例

Analysis on the impact mechanism of DRG charge and payment integration reform: Taking Quanzhou city and Sanming city in Fujian province as examples

DRG收付费一体化改革仍是深化医保支付方式改革的重点内容,但是尚处地方试点探索阶段,其影响机制有待探讨。本研究基于博弈论,从患者、医保部门、医疗机构三个利益相关者出发,以福建泉州市和三明市改革模式为例进行运行模式分析。研究发现,患者侧的收费标准差异是影响改革结果的重要内容,收费标准“一刀切”容易加剧患者自付负担;在合理的预算控制和支付标准下有助于缓解医保基金支出负担;改革能够激励医疗机构节约医疗成本,仍需防范不合理医疗行为。建议患者侧仍依据实际发生医疗费用进行比例结算,以病组支付标准作为自付上限;合理制定年度预算,协同医疗服务价格动态调整机制和药品耗材集中采购等,推动支付标准的合理确定;加强监管机制,防范病组高套。

The integration reform of DRG charge and payment is still a key aspect of deepening the reform of medical insurance payment methods,but it is still in the stage of local pilot exploration,and its impact mechanism needs to be explored.Based on game theory,this study analyze the operating modes from three stakeholders of patients,medical insurance departments,and medical institutions,and takes the reform models of Quanzhou city and Sanming city in Fujian province as examples.Research has found that the difference in the charging standards on the patient side is an important factor affecting the results of the reform,and the“one-size-fits-all”charging standards on the patient side are easy to exacerbate the burden of self-payment by patients.Under reasonable budget control and payment standards,it helps to alleviate the burden of medical insurance fund expenditure.Reform can motivate medical institutions to save medical costs,but it is still necessary to prevent irrational medical behavior.It is recommended that the medical insurance department settle a self-payment ratio based on the actual medical expenses,with the DRG payment standard as the upper limit for the sake of the patient side.Reasonably formulate the annual budgets,coordinate with the dynamic adjustment mechanism of medical service prices and centralized procurement of drug consumables,etc.to promote the reasonable determination of payment standards.Strengthen supervision mechanisms to prevent upcoding of disease groups.