医保付费总额控制对医院经济运行的评价研究

发布时间：2018-05-09 15:38

本文选题：总额控制 + 经济运行　；参考：《广西医科大学》2016年硕士论文

【摘要】：背景：随着我国深化医药卫生体制改革步伐的不断前进,公立医院改革的问题日益突出,医疗费用快速上涨,医保基金支出规模的不断膨胀,“看病难、看病贵”问题仍旧是阻碍我国社会经济发展的重大民生问题之一。支付方式改革作为公立医院改革的重要环节,对医保费用的控制起关键作用,目前我国各省市统筹地区都在积极探索控制费用的支付方式改革,改革势在必行。2013年,广西壮族自治区对中区直驻邕单位职工基本医疗保险定点医院进行医保付费总额控制支付方式改革。目的：本研究通过对总额控制的设计方案和案例医院的实施效果进行研究,分析医院执行情况及应对措施,评价该政策对医院经济运行尤其是医疗费用、医保费用、次均费用等方面的影响并探讨其中存在的问题和产生问题的原因,为今后不断完善医保付费总额控制政策提出合理化建议。方法：通过文献研究和实地调查,归纳整理国内外总额控制的相关理论以及评价医院经济运行的理论知识和分析方法。通过现场调研,对相关人员开展半结构式访谈,了解总额控制方案的实施背景和执行情况,收集2010-2013年间案例医院就诊患者相关数据和N市医疗保险基金基础数据。运用“结构-行为-绩效”分析方法对改革方案设计、医院应对管理措施和医务人员认知等方面进行定性分析。运用SPSS21.0统计软件对数据进行清洗和统计,综合运用假设检验、中断时间序列分析法和倍差法,从医疗服务量、工作效率、医疗费用和医疗质量四个维度,从改革前后医院总体情况、职工医保病人总体情况、职工医保门诊/住院病人情况和典型疾病组比较等四个层面来进行数据分析,来评价实施医保付费总额控制对医院经济运行的影响。结果：医保付费总额控制政策实施后,定点医院已经形成控费意识,医保基金支出的增长趋势逐渐回归正常轨道。医疗服务量总体上涨,医疗服务效率不断提高；医疗费用快速上涨趋势得到控制,但成效有限；医保费用在可控范围内,基金运行状态良好；次均费用增长速度下降,药占比得到有效控制；医院主动增强成本控制和医疗服务质量管理。结论：医保付费总额控制支付方式具有一定的科学性与合理性,总额控制政策实施效果已初步显现。但在政策实施过程中也存在着一些问题,为完善医保付费总额控制方案,提出以下建议：合理制定总控指标测算模型和结算标准；完善大病保险政策,合并实施基本医保和大病保险；加强医院内部运行管理,落实科室责任；未来进一步探索总控政策下的DRGs付费方式。
[Abstract]:Background: with the continuous progress of deepening the reform of the medical and health system in our country, the problems of the reform of public hospitals are increasingly prominent, the medical expenses are rising rapidly, the scale of the medical insurance fund is expanding, "it is difficult to see a doctor," The problem of expensive medical treatment is still one of the major livelihood problems hindering the social and economic development of our country. As an important link in the reform of public hospitals, the reform of payment mode plays a key role in controlling the cost of medical insurance. At present, all provinces and cities in our country are actively exploring the reform of the payment mode of controlling expenses, and it is imperative to reform in 2013. Guangxi Zhuang Autonomous region has carried out the reform of the control and payment method of the total amount of medical insurance payment in the designated hospitals of basic medical insurance for the workers in the Central District of Guangxi. Objective: through the research on the design scheme of total amount control and the effect of the implementation of the case hospital, to analyze the hospital implementation and countermeasures, and to evaluate the policy to the hospital economic operation, especially the medical expenses, medical insurance costs. This paper discusses the problems and causes of the sub-average cost, and puts forward some reasonable suggestions for perfecting the policy of controlling the total amount of medical insurance payment in the future. Methods: through literature research and field investigation, the related theories of total amount control at home and abroad and the theoretical knowledge and analytical methods of evaluating hospital economic operation were summarized and sorted out. Through the field investigation, we conduct semi-structured interviews to the relevant personnel to understand the implementation background and implementation of the total control program, and collect the relevant data of patients in the case hospital from 2010 to 2013 and the basic data of the medical insurance fund of N city. The structural-behavioral-performance analysis method is used to analyze the reform scheme design, hospital management measures and medical staff cognition qualitatively. Using SPSS21.0 statistical software to clean and statistics the data, using hypothesis test, interrupt time series analysis and double difference method, from four dimensions of medical service quantity, work efficiency, medical cost and medical quality. The data are analyzed from four aspects: the general situation of hospitals before and after the reform, the general situation of employees' medical insurance patients, the outpatient / in-patient situation of workers' medical insurance, and the comparison of typical disease groups. To evaluate the impact of the implementation of total health insurance payment control on the economic operation of hospitals. Results: after the implementation of the policy of controlling the total amount of medical insurance payment, the consciousness of controlling the fee has been formed in the designated hospitals, and the increasing trend of the expenditure of the medical insurance fund has gradually returned to the normal track. The overall amount of medical services has risen, the efficiency of medical services has been continuously improved, the trend of rapid increase in medical costs has been controlled, but the results have been limited, the medical insurance costs are in a controllable range, the fund is in good condition, and the growth rate of sub-average costs has decreased. The ratio of drug to drug was effectively controlled, and the hospital actively enhanced cost control and medical service quality management. Conclusion: the method of controlling the total amount of medical insurance payment is scientific and reasonable, and the effect of the total amount control policy has been shown. However, there are still some problems in the process of implementing the policy. In order to improve the control scheme of the total amount of medical insurance payment, the following suggestions are put forward: the reasonable formulation of the calculation model and the settlement standard of the general control index, the improvement of the insurance policy for serious illness, The combination of basic medical insurance and serious illness insurance; strengthening the hospital internal operation management to implement the responsibility of the department; further explore the general control policy under the DRGs payment method in the future.
【学位授予单位】：广西医科大学
【学位级别】：硕士
【学位授予年份】：2016
【分类号】：F842.684

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