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
发布时间：2019-04-15 18:35
【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。
[Abstract]:Objective: to establish a head-to-head payment standard for outpatients based on risk adjustment. Methods: using the data of Shenzhen Social Medical Insurance Information system from 2014 to 2015, descriptive statistics were used to describe the insurance situation and medical treatment, and two models were used to model and estimate the risk adjustment model. Results: the average monthly total cost of outpatients was estimated to be 6.17 yuan, and age, sex, grade of insurance coverage, slow disease or serious illness were selected as risk adjustment factors, and the risk adjustment factors included age, sex, medical insurance coverage grade, slow disease or serious illness. Based on this, the head cost criteria for 52 different population groups were established. Conclusion: according to the risk of health service and the risk adjustment of head-to-head payment, a relatively operational method of head-cost adjustment is established, which can provide reference for the reform of head-to-head payment and the further study in the future.
【作者单位】： 华中科技大学同济医学院医药卫生管理学院;南方医科大学南方医院;华中科技大学同济医学院附属同济医院;
【基金】：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)
【分类号】：F842.684;R197.1
本文编号：2458378
[Abstract]:Objective: to establish a head-to-head payment standard for outpatients based on risk adjustment. Methods: using the data of Shenzhen Social Medical Insurance Information system from 2014 to 2015, descriptive statistics were used to describe the insurance situation and medical treatment, and two models were used to model and estimate the risk adjustment model. Results: the average monthly total cost of outpatients was estimated to be 6.17 yuan, and age, sex, grade of insurance coverage, slow disease or serious illness were selected as risk adjustment factors, and the risk adjustment factors included age, sex, medical insurance coverage grade, slow disease or serious illness. Based on this, the head cost criteria for 52 different population groups were established. Conclusion: according to the risk of health service and the risk adjustment of head-to-head payment, a relatively operational method of head-cost adjustment is established, which can provide reference for the reform of head-to-head payment and the further study in the future.
【作者单位】： 华中科技大学同济医学院医药卫生管理学院;南方医科大学南方医院;华中科技大学同济医学院附属同济医院;
【基金】：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)
【分类号】：F842.684;R197.1
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