摘要
目的:探讨广东省在医保支付改革背景下实施DIP基层病种与DRG基础病组的实践经验,为优化基层医疗资源配置提供参考。方法:综合文献分析、关键知情人访谈及典型案例研究,系统收集2019-2024年广东省10个地市基层病种与基础病组目录的政策文本与实践数据,分析其设置特点、实施效果及存在问题。结果:在广东省10个地市中,8个地市实施DIP付费,2个实施DRG付费;仅4个地市明确基层病种政策要求,1个提及基础病组。各地病种目录数量差异显著,医疗机构系数设置缺乏统一标准,信息化建设滞后,基层病种医保费用占比偏低。典型案例显示,广州市通过调整医疗机构系数引导小病回归基层,基层医疗机构长期住院患者收治量增长超30%。结论:需制定基层医保支付技术规范,统一病种目录设置标准,加强中医病种推广;优化医疗机构系数适配性,推动医保信息平台互联互通,完善智能化监管机制,以提升基层医疗服务能力与医保基金使用效率。
Objective:To explore Guangdong Province’s practical experience in implementing DIP primary disease categories and DRG basic disease groups under the background of medical insurance payment reform,providing references for optimizing the allocation of primary healthcare resources.Methods:Using literature review,key informant interviews,and case study methods,policy texts and practice data from 2019 to 2024 were collected from ten prefecture-level cities in Guangdong Province concerning primary disease categories and basic disease group catalogs.The study analyzed their design characteristics,implementation effects,and existing problems.Results:Among the ten cities,eight implemented DIP-based payment and two adopted DRG-based payment.Only four cities had explicit policies on primary disease categories,and one mentioned basic disease groups.Significant variations existed in the number of disease categories across regions,with no unified standard for setting institutional coefficients,lagging informatization construction,and low proportions of medical insurance expenses for primary diseases.A typical case from Guangzhou demonstrated that adjusting institutional coefficients effectively guided patients with minor illnesses back to primary institutions,with the admission volume of long-term inpatients in primary medical facilities increasing by more than 30%.Conclusion:It is necessary to establish technical specifications for primary medical insurance payment,unify standards for disease catalog design,and strengthen the promotion of traditional Chinese medicine disease categories.Additionally,optimizing the adaptability of institutional coefficients,promoting interconnectivity of medical insurance information platforms,and improving intelligent supervision mechanisms will help enhance primary healthcare service capacity and improve the efficiency of medical insurance fund utilization.
作者
刘灿
李琨
陈凌珊
刘俊雄
胡杨木
肖瑶
LIU Can;LI Kun;CHEN Lingshan;LIU Junxiong;HU Yangmu;XIAO Yao(School of Health Management,Guangzhou Medical University,Guangzhou,Guangdong Province,511436,PRC)
出处
《中国医院》
北大核心
2025年第12期46-49,共4页
Chinese Hospitals
基金
教育部人文社会科学研究青年基金项目(24YJC630075)
国家级大学生创新训练项目(202410570028)
广医大一流专业建设项目-学生创新能力提升项目(02-408-240603131038)
广东省高校基于大数据利用的卫生健康治理哲学社会科学重点实验室(2023WSY007)阶段性成果。
关键词
DIP
DRG
医保支付
基层病种
基础病组
DIP
DRG
medical insurance payment
primary disease category
basic disease group
