[1]何琼刘晨红.DRG支付改革形势下的医疗服务行为持续改进[J].中国卫生质量管理,2023,30(08):068-70.[doi:10.13912/j.cnki.chqm.2023.30.8.14 ]
 HE Qiong,LIU Chenhong.Continuous Improvement in Health Care Practice in the context of DRG Payment Reform[J].Chinese Health Quality Management,2023,30(08):068-70.[doi:10.13912/j.cnki.chqm.2023.30.8.14 ]
点击复制

DRG支付改革形势下的医疗服务行为持续改进
分享到:

《中国卫生质量管理》[ISSN:1006-7515/CN:CN 61-1283/R]

卷:
第30卷
期数:
2023年08期
页码:
068-70
栏目:
医保质量
出版日期:
2023-08-15

文章信息/Info

Title:
Continuous Improvement in Health Care Practice in the context of DRG Payment Reform
作者:
何琼刘晨红
复旦大学附属妇产科医院
Author(s):
HE QiongLIU Chenhong
Obstetrics and Gynecology Hospital Affiliated to Fudan University
关键词:
DRG医保监管医保拒付医保基金三级专科医院
Keywords:
Diagnosis Related Group (DRG) Medical Insurance Supervision Medical Insurance Denied Payment Medical Insurance Fund Tertiary Specialized Hospital
分类号:
R197.5
DOI:
10.13912/j.cnki.chqm.2023.30.8.14
文献标志码:
B
摘要:
目的探讨DRG支付改革形势下医院医保基金的监管情况,促进医疗服务行为持续改进。方法通过分析上海市某三级专科医院2021年医保审核情况,明确医保拒付原因,提出改进对策。结果2021年医保审核条目12 665条,医保拒付条目2 693条,医保拒付金额1 804 967元。医保拒付条目数较多的项目有违规收费(42.8%)、医用耗材审核问题(20.4%)、超限定频次(19.6%)和超限定范围用药(11.6%),医保拒付金额最多的项目为违规收费(123 900元)。结论医院可从组织、管理、技术和经济4个层面规范医疗服务行为,以适应DRG改革形势下的医保监管要求,促进医院健康可持续发展。
Abstract:
Objective To explore the supervision of hospital medical insurance fund under the situation of DRG payment reform, and improve the use efficiency of medical insurance fund. MethodsBy analyzing the medical insurance audit of a tertiary specialized hospital in Shanghai in 2021, the reasons for medical insurance refusal were clarified and the countermeasures for improvement were put forward.ResultsIn 2021, there were 12 665 hospital medical insurance review entries, 2 693 medical insurance denials, 1 804 967 yuan in medicare denials. The items with the highest number of denials were illegal charges (42.8%) ,medical consumables review (20.4%), over-limit frequency(19.6%) and over-limit medication(11.6%).Among them,the item with the highest amount of rejection by the mesical insurance was illegal charges(123 900 yuan).Conclusion Hospitals can standardize medical insurance service behavior from the four levels of organization, management, technology and economy, so as to adapt to the requirements of medical insurance supervision under the situation of DRG reform and promote the healthy and sustainable development of hospitals.

参考文献/References:

[1]国家医保局.2021年全国医疗保障事业发展统计公报[Z].2022-06-08. [2]国务院.医疗保障基金使用监督管理条例[Z].2021-02-19. [3]王宇,郑丹桂,蔡月桃,等.医保智能审核在医院管理中的实践和思考[J].现代医院管理,2020,18(6):72-75. [4]罗碧眉, 蒋南, 刘建明. 限制性用药政策下医院医保用药管理对策探讨[J]. 医药前沿, 2018, 8(24):371. [5]理查德·L.达夫特.组织理论与设计[M].10版.北京:清华大学出版社,2011:15. [6]童雪君,杨帆,金华岭,等.医院医保管理面临挑战与对策探讨[J].江苏卫生事业管理,2021,32(12):1616-1618. [7]吴镝娅,张丽华,刘艳,等.基于DRG的公立医院精细化成本管控实践探讨[J].中国卫生质量管理,2023,30(1):39-43. [8]张光耀,朱公建.医院医保基金监管工作的思考[J].甘肃医药,2021,40(8):753-754,768. [9]李琦,张雨晴,俞乔.北京市海淀区社区医院的医保拒付原因分析及对策建议[J].中国卫生经济,2022,41(6):22-25. [10]滕世伟,李天俊,杨华,等.某三级医院住院医保药品拒付现状分析和管理[J].医药导报,2022,41(12):1767-1771. [11]丁宁,许栋,夏家红,等.DRG支付方式改革下公立医院高质量发展路径探讨[J].中国医院管理,2023,43(3):81-85. [12]孟朝琳,蔡源益,吴华章,等.DRGs实施效果评价研究与思考[J].中国卫生质量管理,2021,28(2):35-38.

相似文献/References:

[1]李刚刘继红胡春平罗博特.通过DRG探析男科学发展路径[J].中国卫生质量管理,2021,28(06):043.[doi:10.13912/j.cnki.chqm.2021.28.6.12 ]
 LI Gang,LIU Jihong,HU Chunping.Exploring the Development Path of Andrology through DRG[J].Chinese Health Quality Management,2021,28(08):043.[doi:10.13912/j.cnki.chqm.2021.28.6.12 ]
[2]董乾王富敏刘厚福房耘耘.DRG对住院费用与服务的影响及建议[J].中国卫生质量管理,2021,28(12):022.[doi:10.13912/j.cnki.chqm.2021.28.12.07 ]
 DONG Qian,WANG Fumin,LIU Houfu.The Impact of DRG on Hospitalization Costs and Services and Recommendations[J].Chinese Health Quality Management,2021,28(08):022.[doi:10.13912/j.cnki.chqm.2021.28.12.07 ]
[3]范晓琪宋多王智帆管宏才李乔晟简伟研王岩.DRG付费对医生行为和医疗质量的影响研究:以踝关节和脊柱融合术为例[J].中国卫生质量管理,2022,29(08):046.[doi:10.13912/j.cnki.chqm.2022.29.8.11 ]
 FAN Xiaoqi,SONG Duo,WANG Zhifan.Impact of DRG Reform on Doctors' Behaviors and Medical Quality: Taking Ankle and Spinal Arthrodesis as Examples[J].Chinese Health Quality Management,2022,29(08):046.[doi:10.13912/j.cnki.chqm.2022.29.8.11 ]
[4]吴镝娅张丽华刘艳蔡林.基于DRG的公立医院精细化成本管控实践探讨[J].中国卫生质量管理,2023,30(01):039.[doi:10.13912/j.cnki.chqm.2023.30.1.10 ]
 WU Diya,ZHANG Lihua,LIU Yan.Practice of Lean Cost Control in Public Hospitals Based on Diagnosis Related Group[J].Chinese Health Quality Management,2023,30(08):039.[doi:10.13912/j.cnki.chqm.2023.30.1.10 ]
[5]方金鸣陶红兵.基于博弈理论的DRG支付对三级医院疾病诊治难度的影响分析[J].中国卫生质量管理,2023,30(07):024.[doi:10.13912/j.cnki.chqm.2023.30.7.06 ]
 FANG Jinming,TAO Hongbing.Influence of DRG Payment on the Difficulty of Diagnosis and Treatment of Diseases in Tertiary Hospitals Based on Game Theory[J].Chinese Health Quality Management,2023,30(08):024.[doi:10.13912/j.cnki.chqm.2023.30.7.06 ]
[6]朱慧吴俊霞.某传染病专科医院临床科室医疗服务能力评价与分析[J].中国卫生质量管理,2023,30(08):030.[doi:10.13912/j.cnki.chqm.2023.30.8.07 ]
 ZHU Hui,WU Junxia.Evaluation and Analysis of Medical Service Capability of Clinical Departments in a Certain Infectious Disease Specialized Hospital[J].Chinese Health Quality Management,2023,30(08):030.[doi:10.13912/j.cnki.chqm.2023.30.8.07 ]
[7]刘颜张海峤陈寒杰靳洁孙逸凡林创鹏汤鑫徐源许昌陈芸.基于电子病历的智慧医保探讨[J].中国卫生质量管理,2023,30(10):015.[doi:10.13912/j.cnki.chqm.2023.30.10.04 ]
 LIU Yan,ZHANG Hanqiao,CHEN Hanjie.Exploration of Smart Medical Insurance Based on Electronic Medical Records[J].Chinese Health Quality Management,2023,30(08):015.[doi:10.13912/j.cnki.chqm.2023.30.10.04 ]
[8]魏巍孙明徐茂云.DRG支付下IF55病种医用耗材应用现状与对策研究[J].中国卫生质量管理,2023,30(12):028.[doi:10.13912/j.cnki.chqm.2023.30.12.07 ]
 WEI Wei,SUN Ming,XU Maoyun.Application Status and Countermeasures of IF55 Medical Consumables under DRG Payment[J].Chinese Health Quality Management,2023,30(08):028.[doi:10.13912/j.cnki.chqm.2023.30.12.07 ]
[9]沈婷于海跃钟力炜朱佳云张娴静李群朱乐兰.临床专科评价的DRG细化分组机制研究[J].中国卫生质量管理,2024,31(03):012.[doi:10.13912/j.cnki.chqm.2024.31.3.04]
 SHEN Ting,YU Haiyue,ZHONG Liwei.DRG Refinement Grouping Mechanism of Clinical Specialty Departments Evaluation[J].Chinese Health Quality Management,2024,31(08):012.[doi:10.13912/j.cnki.chqm.2024.31.3.04]
[10]王晓奕 洪乃坤 陈寒杰 刘颜 钟婉婷 成思 任妮丽 孔少楠 董四平 许昌.基于价值医疗理念的公立医院DRG运营管理策略实证研究[J].中国卫生质量管理,2024,31(11):025.[doi:10.13912/j.cnki.chqm.2024.31.11.06]
 WANG Xiaoyi,HONG Naikun,CHEN Hanjie.An Empirical Study on the DRG Operation and Management Strategy of Public Hospital Based on the Concept of Value Medical Care[J].Chinese Health Quality Management,2024,31(08):025.[doi:10.13912/j.cnki.chqm.2024.31.11.06]

更新日期/Last Update: 2023-08-15