摘要
目的:通过总结中医优势病种支付方式改革的实践经验,分析共性问题并提出对策,为进一步完善各地区试点方案并探索适合中医药特征的医疗保险支付方式提供科学依据。方法:聚焦中医优势病种及支付方式改革的实践进展、共性病种、服务类型3个维度,对资料进行整理和分析。结果:研究发现各地探索的中医药支付方式包括中医优势病种付费、单独设立中医DRG分组、设置中医院差异化调节系数三类。改革方案以扩展按病种付费范围、单病种付费、按疗效价值付费三类为主。改革成效主要体现在中医价值得到认可、医院获得支持、患者受益三方面。共性病种主要包括骨伤类、痹病及肛肠类疾病。服务类型以住院为主,部分地区拓展至门诊和日间治疗。结论:当前中医优势病种支付主要存在改革与服务范围局限、中西医编码体系及病案填写不够规范、绩效激励配套不足、费用测算不尽合理等问题。建议提出探索“住院一门诊一居家”整合型中医优势病种服务模式、形成中医病种管理范式、补偿短期政策性亏损并调整价格、利用大数据和人工智能优化算法并科学制定临床路径标准等对策建议。
Objective:It aimed to improve pilot programs and explore medical insurance payment methods tailored to the characteristics of Traditional Chinese Medicine(TCM)services by summarizing practical experiences,analyzing common issues,and proposing strategic suggestions.Methods:It conducted a comprehensive review of literature and policy documents to analyze the progress of TCM advantageous condition and payment modality reforms,prevalent conditions,and service types.Results:It revealed various payment modalties for TCM,including remuneration for advantageous conditions,establishment of TCM Diagnosis Related Groups(DRG),and formulation of differential adjustment coefficients for TCM-focused healthcare institutions.Reforms predominantly involve expanding condition-based remuneration scopes,individual-condition remunerations,and remuneration based on therapeutic efficacy.The effect of the reform is mainly reflected in the recognition of the value of TCM,the support of hospitals,and the benefit of patients.Predominant conditions include bone injuries,rheumatic ailments,and anorectal disorders,with hospitalization being the primary service modality.Conclusion:Current payment modalities for TCM advantageous conditions face challenges such as limited reform scope and service coverage,coding system standardization issues,performance incentive deficiencies,and irrational cost estimation.Recommendations include exploring integrated TCM advantageous condition service models,establishing a management paradigm for TCM conditions,addressing transient policy-related deficits,leveraging data analytics and AI algorithms,and formulating clinical pathway standards.
作者
张诗文
王丽丽
荆丽梅
张小雨
王静蓉
金慧鑫
Zhang Shiwen;Wang Lili;Jing Limei(School of Public Health,Shanghai University of Traditional Chinese Medicine,Shanghai,201203,China;不详)
出处
《中国卫生经济》
北大核心
2024年第8期22-27,33,共7页
Chinese Health Economics
基金
首都医科大学国家医疗保障研究院项目(YB2023B08)
上海市卫生经济学会科研项目(HXZZ09)
上海市黄浦区卫生健康委员会委托课题。
关键词
中医优势病种
支付方式改革
经验介绍
dominant diseases in traditional Chinese medicine
payment reform
experience introduction
作者简介
通信作者:荆丽梅,E-mail:limei_jing@sjtu.edu.cn。
