通讯作者: 项莉, xllyf@126.com

DOI：10.12201/bmr.202311.00001

Analysis of the Impact Mechanism of DRG pricing and payment reform Integration Reform——Taking Quanzhou and Sanming in Fujian as examples

• 摘要：DRG收付费一体化改革仍是深化医保支付方式改革的重点内容，但是尚处地方试点探索阶段，其影响机制有待探讨。本研究基于博弈论，从患者、医保部门、医疗机构三个利益相关者出发，以福建泉州市和福建三明市改革模式为例进行运行模式分析。研究发现，患者 侧的收费标准差异是影响改革结果的重要内容，患者侧的收费标准“一刀切”容易加剧患者自付负担；在合理的预算控制和支付标准下有助于缓解医保基金支出负担；改革能够激励医疗机构节约医疗成本，仍需防范不合理医疗行为。建议患者侧仍依据实际发生医疗费用进行比例结算，以病组支付标准作为自付上限；合理制定年度预算，协同医疗服务价格动态调整机制和药品耗材集中采购等，推动支付标准的合理确定；加强监管机制防范病组高套。

  关键词： DRG; 收付费改革; 医保支付方式; 影响机制; 福建

   

  Abstract: The integration reform of DRG pricing and payment is still a key aspect of deepening the reform of medical insurance payment methods, but it is still in the stage of local pilot exploration, and its impact mechanism needs to be explored. This study is based on game theory, starting from three stakeholders: patients, medical insurance departments, and medical institutions, and using the reform models of Quanzhou and Sanming in Fujian Province as examples to analyze the operating modes. Research has found that the difference in fee standards for patient testing is an important factor affecting the results of the reform, and the one size fits all fee standards for patient testing can easily exacerbate the risk of self-payment by patients. Under reasonable budget control and payment standards, it helps to alleviate the burden of medical insurance fund expenditure。Reform can motivate medical institutions to save medical costs, but it is still necessary to prevent unreasonable medical behavior. It is recommended that the medical insurance department set a self-payment ratio based on the actual medical expenses incurred, with the DRG payment standard as the upper limit. Reasonably formulate the annual budget, coordinate the dynamic adjustment mechanism of medical service prices and centralized procurement of drug consumables, and promote the reasonable determination of payment standards. Strengthen regulatory mechanisms to prevent medicare upcoding.

  Key words: DRG；pricing and payment reform; Medical insurance payment method; Impact mechanism; Fujian; 

  提交时间：2023-11-17

  版权声明：作者本人独立拥有该论文的版权，预印本系统仅拥有论文的永久保存权利。任何人未经允许不得重复使用。
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• 序号	提交日期	编号	操作
  1	2023-08-29	bmr.202311.00001V1	下载

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