美国门诊预付费系统支付方式研究及启示

Study on the Payment Method of Ambulatory Payment Classification System in the United States and Its Implications for China

目的:梳理美国门诊预付费系统(APC)的发展历程、分组方案及付费方式,为我国探索门诊医保支付方式改革提供参考。方法:基于文献研究,系统总结美国APC的主要措施与特点。结果:美国APC以医疗保健通用程序编码系统为基础,基于临床、资源消耗相似原则及成本二倍规则,对门诊医疗服务项目进行分组,考虑门诊医疗服务特征形成多样化支付单元。结论:我国可借鉴美国APC,建立门诊预付费制度,需考虑门诊医疗服务特点合理设计支付政策,完善门诊医疗服务编码系统,兼顾创新技术发展需求,并做好不同支付方式之间的统筹协调工作。

Objective To study the development history,grouping scheme and payment method of the Ambulatory Payment Classification(APC)in the United States,and to provide reference for China to explore the reform of outpatient health insurance payment method.Methods Based on the literature review,the main measures and characteristics of the APC in the United States were systematically summarized.Results Based on Healthcare Common Procedure Coding System(HCPCS),APC payment system grouped outpatient health services according to the principles of clinical and resource consumption similarity as well as the two times cost rule,and formed diversified payment units by considering the characteristics of outpatient health services.Conclusion China can learn from APC payment system in the United Status and establish an outpatient prospective payment system.It is necessary to take into account the characteristics of outpatient health services to rationally design the payment policies,improve the coding system for outpatient health services,balance the development needs of innovative technologies,and coordinate different payment methods.