门诊病例组合系统的国际经验及启示

International Experience and Enlightenment of Outpatient Case-mix System

当前我国门诊费用不断增长,付费机制不够成熟,门诊医保支付方式改革处于起步阶段。美国、韩国、英国较早开始研究并建立门诊病例组合系统,积累了一定的经验,能够为我国建立门诊病例组合系统、推动门诊医保支付方式改革提供参考。主要启示有:建立适用于全部门诊范围的病例组合系统,组建专业团队完善编码系统,建立以操作为初始分类变量、诊断和辅助服务为次变量的分组逻辑,单个患者可分配多个组别以保证同质性,使门诊支付方式与住院支付方式相配套。

At present,China's outpatient costs are increasing,the payment mechanism is not mature enough,and the reform of outpatient health insurance payment method is in initial stage.The United States,South Korea and the United Kingdom have established outpatient case-mix systems earlier,and accumulated certain experience,which can provide reference for China to establish outpatient case-mix system and promote payment method reform of outpatient medical insurance.For example,it is necessary to establish a case-mix system applicable to the entire outpatient scope,set up a professional team to improve the coding system,establish a grouping logic with operation as the initial categorization variable and diagnosis and auxiliary services as the secondary variables,assign a single patient to more than one group to ensure the homogeneity,and make the outpatient payment method match with the inpatient payment method.