南京市中医DRG分组付费改革的成效、经验与展望

The Effectiveness,Experience,and Prospects of Traditional Chinese Medicine DRG Payment Reform in Nanjing

在按疾病诊断相关分组(Diagnosis Related Groups,DRG)付费方式改革大潮中,中医特色和价值优势没有得到充分体现。南京市自2022年起开创中医DRG分组付费方式,改革成效亟须系统性评估。从服务可及性、质效可靠性、费用可控性三个维度对南京市中医DRG分组付费改革效果进行评估,结果表明,政策实施后,纳入中医DRG分组付费的中医特色病种在服务可及性、质效可靠性、费用可控性上总体呈现出明显优势。机构覆盖率、病组覆盖率和病组病例数均明显增长,中医医疗服务质量和效率明显增强,医保基金对纳入中医DRG分组付费的中医特色病种的倾斜支持力度逐年上升。南京市中医DRG分组付费改革经验主要体现在病证结合、科学编码、就高倾斜和数据赋能等方面,但仍存在分组方案不均衡、证候分型管理有待加强和疗效价值体现不明显等不足。未来,建议进一步扩大DRG分组付费范围,提升服务可及性;协同加强医疗机构院内管理,提升质效可靠性;强化中医医保支付政策引导,提升费用可控性;探索中医疗效价值评价体系,提升支付效能度。

In the wave of diagnosis related groups(DRG)payment reform,the characteristics and value of traditional Chinese medicine(TCM)have not been fully reflected.Since 2022,Nanjing has been pioneering the TCM-DRG payment,and the effectiveness of the reform urgently needs systematic evaluation.This article evaluates the effectiveness of the TCM-DRG payment reform in Nanjing from three dimensions:service accessibility,quality and effectiveness reliability,and cost controllability.The results show that after policy implementation,diseases of TCM characteristics included in TCM-DRG payment show significant advantages in service accessibility,quality and effectiveness reliability,and cost controllability overall.The institutional coverage,disease group coverage,and number of disease group cases have all significantly increased,the quality and efficiency of TCM medical services have significantly improved,and the support of the medical insurance fund for diseases of TCM characteristics included in the DRG payment has been increasing year by year.The experience of the TCM-DRG payment reform in Nanjing mainly lies in the combination of disease and syndrome,scientific coding,incentive measures,and data empowerment,but there are still shortcomings in group balance,syndrome classification,and value embodiment.In the future,it is recommended to further expand the scope of DRG payment and improve service accessibility;strengthen management inside medical institutions and improve quality and effectiveness reliability;strengthen the guidance of medical insurance payment policies and improve the controllability of expenses;explore the value evaluation system for TCM efficacy and improve payment efficiency.