摘要
医疗保险在医疗服务项目价格管制基础上,通过支付方式改革,实现对医疗服务总费用管制。文章分析了医疗服务价格形成与按DRG/DIP付费的冲突:按历史例均费用而非诊疗成本测算医保支付标准,延续了项目不合理比价关系;新技术、特需医疗服务病例与DRG/DIP付费衔接不畅,阻碍优质优价需求。梳理了各地新增医疗服务项目、实行市场调节价非基本医疗服务项目价格形成与医保支付的衔接做法,获得其他地区对促进医疗服务价格分类形成与医保DRG/DIP付费协同的启示:将成本信息充分应用于医疗服务价格合理形成和病组(病种)支付标准制定;结合真实世界数据和卫生技术评估,辅助创新医疗技术定价和支付准入决策;完善DRG/DIP新技术特例单议纳入标准、申报程序、审核流程、结算办法;将符合条件的特需医疗服务病例费用不纳入DRG/DIP付费标准和费用清算。
Based on the price control of medical service items,medical insurance realizes the total cost control of medical services through the reform of payment methods.It analyzes the conflicts between the medical service price formation and payment based on DRG/DIP:measuring the medical insurance payment standard according to the historical average case cost rather than the diagnosis and treatment cost,and continuing the unreasonable price comparison relationship of items;new technologies,special medical service cases and DRG/DIP payment are not well connected,which hinders the demand for high quality and high price.It sorts out the linking practices of new medical service items and the implementation of market-regulated prices for non-basic medical service items and medical insurance payment,and obtains the enlightenment of other regions in promoting the formation of medical service price classification and the coordination of medical insurance DRG/DIP payment:fully applies cost information to the formation of reasonable medical service prices and the formulation of payment standards for patient groups(diseases);combines real-world data and health technology assessments to aid innovative medical technology pricing and payment access decisions;improves the inclusion standard,declaration procedure,review process and settlement method of DRG/DIP new technology special case;excludes the costs of eligible special medical care cases from the DRG/DIP payment criteria and fee settlement.
作者
郑大喜
李星
刘静
Zheng Daxi;Li Xing;Liu Jing(Tongji Hospital,Tongji Medical College of HUST,Wuhan,430030,China;不详)
出处
《中国卫生经济》
北大核心
2025年第3期47-53,共7页
Chinese Health Economics
作者简介
通信作者:刘静,E-mail:56999744@qq.com。
