| 引用本文：姚强, 张晓丹, 姚岚.DIP医保基金结算流程及关键技术研究[J].中国卫生政策研究,2023,16(3):1-8 |
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| DIP医保基金结算流程及关键技术研究 |
| 投稿时间：2022-12-29 修订日期：2023-03-02 PDF全文浏览 HTML全文浏览 |
| 姚强1,2,3, 张晓丹2, 姚岚3,4 |
1. 武汉大学社会保障研究中心 湖北武汉 430072;
2. 武汉大学政治与公共管理学院 湖北武汉 430072;
3. 国家医保研究院华科基地 湖北武汉 430030;
4. 华中科技大学同济医学院医药卫生管理学院 湖北武汉 430030 |
| 摘要:区域总额预算内的按病种分值付费下医保基金如何结算成为DIP落地的重难点。本研究通过现场调研和政策文献分析建立了DIP医保基金结算的逻辑框架和实施流程。结果显示，以“基金预拨付”“月度预结算”和“年度清算”为核心的结算框架融合了预付制和后付制思想；“月度预结算”作为结算的关键环节，对于分解医保经办机构和医疗机构的年终压力、引导合理医疗行为具有重要作用；“年度清算”作为结算的核心环节决定了医疗机构年度医保基金支付金额，其需要依托并整合区域总额预算、病种分值库及校正、医疗机构监管考核等关键技术；通过出台结算及相关配套政策明确结算流程、测算方法及关键参数，为DIP改革的落地实施和见效提供技术支撑和制度保障。 |
| 关键词:区域总额预算 DIP 结算流程 医保支付方式 |
| 基金项目:国家自然科学基金面上项目(72174149)； 教育部人文社会科学研究规划基金项目(21YJAZH102)； 教育部人文社会科学重点研究基地自设课题(1203-413100050) |
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| The settlement process and key technology exploration on DIP medical insurance fund |
| YAO Qiang1,2,3, ZHANG Xiao-dan2, YAO Lan3,4 |
1. Center for Social Security Studies, Wuhan University, Wuhan Hubei 430072, China;
2. School of Political Science and Public Administration, Wuhan University, Wuhan Hubei 430072, China;
3. HUST Base of National Institute of Healthcare Security, Wuhan Hubei 430030 China;
4. School of Medicine and Health Management of Tongji College, Huazhong University of Science and Technology, Wuhan Hubei 430030, China |
| Abstract:Thekey point-tothe implementation of the big data diagnosis & intervention packet (DIP) is settling of medical insurance fund under the payment according to the value of the disease under the regional total budget.Through on-site survey and policy literature analysis,the logical framework and implementation process of DIP medical insurance fund settlement are established in this study. Theresultsshow that the settlement framework, featuring “Fund pre-allocation”, “Monthly pre-settlement” and “Annual liquidation”,integrates ideas of both pre-payment system and post-payment system.“Monthly pre-settlement” being the key of the settlementprocess, plays an important role in breaking down the year-end pressure of medical insurance agencies and medical institutions and guiding reasonable medical behaviors;“Annual liquidation”acts as the core link of settlement,which determines the annual amount paid by medical insurance fund of medical institutions, which is based onkey technologies such as regional total budget, DIP grouping database and correction, and medical institution supervision and assessment, meanwhile integrates them.It is very important the settlement process, measurement methods and key parameters are clarifiedthrough the issuance of settlement and related supporting policies so that technical support and institutional guarantee are provided for the implementation and effectiveness of the DIP reform. |
| Key words:Regional total budget DIP Settlement process Medical insurance payment methods |
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