| 引用本文：艾丽唤, 吴荣海, 肖黎, 张治国.基于风险调整的基本医疗保险门诊统筹按人头付费标准测算研究——以深圳市为例[J].中国卫生政策研究,2017,10(9):39-45 |
|
| 基于风险调整的基本医疗保险门诊统筹按人头付费标准测算研究——以深圳市为例 |
| 投稿时间：2017-03-15 修订日期：2017-06-05 PDF全文浏览 HTML全文浏览 |
| 艾丽唤1, 吴荣海2, 肖黎3, 张治国1 |
1. 华中科技大学同济医学院医药卫生管理学院 湖北 武汉 430030;
2. 南方医科大学南方医院 广东 广州 510515;
3. 华中科技大学同济医学院附属同济医院 湖北 武汉 430030 |
| 摘要:目的：建立基于风险调整的门诊统筹按人头付费支付标准。方法：利用深圳市社会医疗保险信息系统2014—2015年的数据，采用描述性统计对参保人员参保情况和就诊情况进行描述，采用两部模型进行风险调整模型建模估计。结果：参保人群月门诊人均总费用预测值为6.17元，同时筛选出年龄、性别、医保参保档次、是否慢病或大病患者4个因素作为风险调整因素，据此确立了52个不同人群组别的人头费用标准。结论：根据参保者的患病风险和预期卫生服务利用对按人头付费进行风险调整，建立相对可操作的人头费用调整方法，为各地开展按人头付费改革和后续进一步研究提供参考。 |
| 关键词:基本医疗保险 门诊统筹 按人头付费 风险调整 |
| 基金项目:国家自然科学基金项目（71273100）；华中科技大学“中央高校基本科研业务费”（2016AB022） |
|
| A Study on methods of risk-adjusted capitation fee of risk pooling for outpatient services in basic medical insurance: A case study of Shenzhen City |
| AI Li-huan1, WU Rong-hai2, XIAO Li3, ZHANG Zhi-guo1 |
1. School of Medicine and Health Management, Tongji Medical College, Huazhong University of Science and Technology, Wuhan Hubei 430030, China;
2. Nanfang Hospital of Southern Medical University, Guangzhou Guangdong 510515, China;
3. Affiliated Tongji Hospital, Tongji Medical College of Huazhong University of Science and Technology, Wuhan Hubei 430030, China |
| Abstract:Objective: The main objective of the present study is to develop the risk-adjusted capitation payment standards to compensate health service providers. Methods: Descriptive statistical analysis was conducted to analyze the insured's enrollment and visit conditions, and the two-part model was conducted to obtain the appropriate compensation standard using data retrieved from information system of social health insurance for the period of 2014 to 2015 in Shenzhen City. Results: The estimated value of total expenditure per insured person per month is 6.17 yuan. Age，sex，insurance level and with or without chronic disease or catastrophic disease were elicited as risk adjustors. The whole number insured people were divided into 52 groups by this four risk-adjustment factors whereby the relevant payment standards for each group was calculated. Conclusions: By adjusting capitation fee on the grounds of risk of disease and expected expense of medical services of the insured, the capitation payment standards can be calculated virtually. This method will promote the process of capitation payment system reform and also lay a solid foundation for further research. |
| Key words:Basic medical insurance Risk pooling of outpatient services Capitation Risk adjustment |
| 摘要点击次数: 2443 全文下载次数: 1069 |
|
|
