金坛市人民医院实行病种支付效果研究

发布时间：2018-02-24 08:06

本文关键词： 医疗保险按病种支付实行效果费用控制　出处：《南京医科大学》2015年硕士论文　论文类型：学位论文

【摘要】：目前,我国三大基本医疗保险的参保率已经提高到90%以上,基本实现了全民覆盖。在当前新医改的大环境下,支付方式的选择不仅关系到医疗费用能否得到有效控制,而且关系到医保基金的收支平衡和医院的持续发展。按病种支付是医保支付方式改革的成果之一。它通过制定预付标准来控制医疗服务提供者的总支出,使医方承担经济风险,有效影响了医疗行为,并在一定程度上控制了不断上涨的医疗费用,使医疗服务公益性、公平性得到更好体现。如何更好地推行按病种支付、合理控制医保患者的医疗费用,对维护患者利益、提高医疗保险基金的运行效率、提升患者的保障水平均具有重要的意义。目的:本文主要依据金坛市人民医院按病种支付的实行效果进行研究分析,研究按病种支付实行前后,医院的经济运行情况、住院医保患者补偿情况、特定病种医疗费用补偿和医疗负担情况、特定病种的药品使用行为的变化情况以及对医疗行为和医疗质量的影响。了解该支付方式的实行效果及其存在问题。方法:此次研究利用文献研究法,搜集国内外按病种支付有关方面的文献,为本课题的研究设计与调查实行提供理论指导;运用定量调查和定性访谈等方法,把金坛市人民医院作为研究对象,通过研究该院的医疗行为主观和客观指标,比较该院自身实行病种支付方式改革前后医疗费用及补偿情况,深入研究特定病种的药品使用行为变化情况,分析按病种支付的实行效果及存在问题。研究结果:(1)医保患者的费用负担得到显著降低;(2)一定程度上规范了医疗行为,医疗质量总体较好;(3)医院效率有所提高;(4)有效降低了患者转外的就诊率。研究结论:本论文通过对金坛市人民医院按病种支付的执行效果以及对医疗行为的影响研究显示:(1)按病种支付制度的执行效果总体较好;(2)患者的医疗负担得到了显著的降低;(3)药品费用的控制仍是按病种支付执行的重点;(4)按病种支付执行中存在一些问题,有待改进。建议:(1)科学制定按病种支付标准;(2)调整支付标准,实行弹性管理;(3)健全临床路径制度,科学管理临床路径的进入和退出机制;(4)加大对医疗机构的监管力度;(5)完善信息支撑政策;(6)完善医疗保障制度;(7)提高中成药的临床使用率。
[Abstract]:At present, the participation rate of the three major basic medical insurance in our country has been raised to more than 90%, which has basically achieved universal coverage. Under the general environment of the current new health care reform, the choice of payment methods is not only related to whether the medical expenses can be effectively controlled, It is also related to the balance of income and expenditure of the medical insurance fund and the sustained development of the hospital. Paying according to disease is one of the achievements of the reform of the medical insurance payment mode. It controls the total expenditure of the medical service provider by establishing the standard of prepayment to make the medical party bear the economic risk. It effectively affects the medical behavior, and to some extent controls the rising medical expenses, so that the commonweal and fairness of the medical service can be better reflected. How to better implement the payment according to the kind of disease, and how to control the medical expenses of the medical insurance patients reasonably, It is of great significance to maintain the interests of patients, improve the operating efficiency of medical insurance fund and improve the level of patient protection. To study the economic operation of hospitals, the compensation of inpatient medical insurance patients, the compensation of medical expenses and the medical burden of specific types of diseases before and after the implementation of payment according to disease. The change of drug use behavior and its influence on medical behavior and quality of medical treatment. Understand the effect of the payment method and its existing problems. Methods: this study used the literature research method, Collect the literature about paying for the disease by disease at home and abroad, provide theoretical guidance for the research design and practice of this subject, use the methods of quantitative investigation and qualitative interview, take the people's Hospital of Jintan City as the research object. By studying the subjective and objective indexes of the hospital's medical behavior, comparing the medical expenses and compensation before and after the reform of the way of paying for the disease, and deeply studying the change of the drug use behavior of the specific disease, The research results show that the cost burden of medical insurance patients has been significantly reduced and the medical behavior has been regulated to a certain extent. The overall quality of medical treatment is better than 3) the efficiency of the hospital has been improved. 4) the rate of patients being transferred to hospital has been reduced effectively. Conclusion: this paper analyzes the effect of the people's hospital in Jintan on the effect of paying according to the disease type and the influence on the medical behavior. The study shows that the implementation of the pay system by disease is generally better. (2) the medical burden of patients has been significantly reduced. (3) the control of drug costs is still the key point in the implementation of payment by disease. 4) there are some problems in the implementation of payment by disease. It is suggested that: 1) establish scientifically the standard of payment according to the disease type and adjust the standard of payment, and implement elastic management to improve the system of clinical pathway. Scientific management of clinical pathway entry and exit mechanism (4) strengthen the supervision of medical institutions (5) improve the information support policy / 6) improve the medical security system / 7) improve the clinical use rate of Chinese patent medicine.
【学位授予单位】：南京医科大学
【学位级别】：硕士
【学位授予年份】：2015
【分类号】：R197.1;F842.684

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