| 引用本文：陈知禾, 林坤河, 钟正东, 周津, 张雨孟, 项莉.DIP支付方式下新生儿科医保结算影响因素分析[J].中国卫生政策研究,2023,16(12):33-39 |
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| DIP支付方式下新生儿科医保结算影响因素分析 |
| 投稿时间：2023-11-08 修订日期：2023-12-09 PDF全文浏览 HTML全文浏览 |
| 陈知禾1, 林坤河1, 钟正东1, 周津1, 张雨孟1, 项莉1,2 |
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. 国家医疗保障研究院华科基地 湖北武汉 430030 |
| 摘要:目的：分析新生儿科DIP医保结算情况及其影响因素，优化新生儿科医保结算规则，推进支付方式改革精细化管理。方法：选择国家DIP支付方式试点城市Y市为案例地区，结合定性资料分析与访谈研究，采用描述性分析、四象限气泡图、多元线性回归方法，对Y市新生儿科全样本患者数据进行分析。结果：Y市2022年有1 372例新生儿，医保结算率为84.82%，其中三级医疗机构为81.10%。未入组718例，占比52.33%。三级医疗机构、未入组、低体重儿、住院天数越高、出生天数越低、结算分值越低的病例，医保结算率越低（P<0.05）。结论：新生儿科医保结算率显著低于全市水平，三级医疗机构亏损程度更高，易引致推诿危重新生儿患者风险；新生儿科存在分组精细化不足、分值失真的问题。建议：完善核心要素管理与调整机制，优化新生儿科DIP病种分组；综合考虑新生儿资源消耗特征、合理动态调整新生儿医疗服务价格、科学设置新生儿科加成系数；做到新生儿科发展与医保协同改进，推进医保支付方式改革内涵式、精细化发展。 |
| 关键词:医保 支付方式 DIP 基金结算 新生儿科 精细化管理 |
| 基金项目:国家自然科学基金（71874058；72174068） |
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| Analysis of influencing factors of medical insurance fund settlement in neonatology under DIP payment method |
| CHEN Zhi-he1, LIN Kun-he1, ZHONG Zheng-dong1, ZHOU Jin1, ZHANG Yu-meng1, XIANG Li1,2 |
1. School of Medical and Health Management, Tongji Medical College of Huazhong University of Science and Technology, Wuhan Hubei 430030, China;
2. HUST Base of National Institute of Healthcare Security, Wuhan Hubei 430030, China |
| Abstract:Objective: To analyze the DIP medical insurance settlement situation of neonatology and its influencing factors, to optimize the medical insurance settlement rules of neonatology, and to promote the fine management of payment method reform. Methods: City Y, the pilot city of national DIP payment method, was selected as the case area, and the data of the whole sample of patients in neonatology department of City Y were analyzed by descriptive analysis, four-quadrant bubble chart, and multivariate linear regression methods, combined with qualitative data analysis and interview study. Results: There were 1 372 neonates in City Y in 2022, with a health insurance billing rate of 84.82% and 81.10% in tertiary care facilities. There were 718 unenrolled cases. Tertiary care institutions, not enrolled, low-birth-weight babies, higher days of hospitalization, lower days of birth, and lower settlement scores were the influencing factors for the low rate of health insurance settlement in neonatology (P<0.05). Conclusion: Neonatology medical insurance settlement rate was significantly lower than that of the city, and tertiary care institutions had higher deficits, which may lead to the risk of shirking critically ill neonatal patients. There were problems of insufficient grouping refinement and score distortion in neonatology. Recommendation: We should improve the management and adjustment mechanism of core elements, optimize the DIP grouping of neonatology, comprehensively consider the resource consumption characteristics of neonates, rationally and dynamically adjust the price of neonatal medical services, and scientifically set the neonatology markup coefficients, so as to achieve synergistic improvement in the development of neonatology and health insurance, and to push forward the connotative and refined development of the reform of the payment method of health insurance. |
| Key words:Medical insurance Payment method DIP Fund settlement Neonatology Refined management |
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