上海市J区DIP医保支付方式改革进展及效果评价

Progress and effectiveness evaluation of DIP health insurance payment reform in J district,Shanghai

目的:了解上海市J区按病种分值付费改革进展,发现并解决实施中存在的问题,保证支付改革的顺利推进。方法:通过文献分析、关键知情人访谈和问卷调查,围绕区域年度预算结算、住院医保基金支出、实施进展以及患者受益4个维度进行研究。结果:2019-2021年,区域年度预算结算总额的差值为负值,尚未达到收支平衡。较改革前相比,区域住院总费用增长幅度有所缓和,住院医保费用增幅有所控制。2022年至今全区适用病例入组占比保持高位水平,病种入组率高于市入组率均值。住院医保患者实际自付比例保持在30%左右,各项满意度均分在4.5分(5分)以上。结论:改革实施进程顺利推进,实际自付比例保持较低水平,患者满意程度高,但改革培训范围有限、信息系统问题凸显,需要扩大培训范围,加快DIP信息化建设。

Objective:To understand the progress of disease-based payment reform in J District,Shanghai,identify and resolve implementation issues,and ensure the smooth advancement of the payment reform.Methods:The study was conducted through literature analysis,key informant interviews,and questionnaire surveys,focusing on four dimensions:regional annual budget settlement,inpatient health insurance fund expenditure,implementation progress,and patient benefits.Results:From 2019 to 2021,the difference between the total regional annual budget settlement amounts was negative,indicating that the balance between income and expenditure had not yet been achieved.Compared to the period before the reform,the growth rate of total regional inpatient costs has moderated,and the increase in inpatient health insurance expenses has been controlled.Since 2022,the proportion of enrolled cases under the reform in the district has remained high,with a case enrollment rate higher than the city’s average.The actual out-of-pocket rate for inpatient health insurance patients remains around 30%,and overall satisfaction scores are above 4.5(out of 5).Conclusion:The reform is progressing smoothly,with a low actual out-of-pocket rate and high patient satisfaction.However,issues such as limited reform training coverage and prominent information system problems highlight the need to expand training scope and accelerate DIP information system development.