建档立卡贫困户住院患者医保资金使用分析及建议

目的对建档立卡贫困户住院患者的医保结算费用进行聚类分析，为医保资金合理使用提供参考。方法以大同市某三级医院2018年1月1日-2020年12月31日建档立卡贫困户住院患者为研究对象，采用K-Means方法对其医保结算费用进行聚类分析。结果患者聚为5类:第1类为过度转诊患者；第2类为疾病在基层医疗机构无法确诊，需要向上转诊已明确诊断的患者；第3类为常见慢性病患者；第4类为反复住院的终末期患者；第5类为医保资金使用的重点人群。费用支付以基本医疗保险、大病保险和医保兜底保障为主。5类患者的年龄、性别、住院次数、诊断个数、危重程度、是否手术、住院天数和住院总费用以及分类医保结算费用的差异均有统计学意义（P＜0.05）。结论建档立卡贫困户的医疗保障政策在减轻患者疾病经济负担的同时，存在医保资金使用不合理问题。建议相关机构加强医保资金使用监督力度，规范患者就医行为，并通过多方努力，逐步建立医疗救助、商业保险、社会救助相结合的健康扶贫制度。

Analysis and Suggestions on the Use of Medical Insurance Funds for Inpatients of Registered Poor Households

ObjectiveTo perform cluster analysis on the medical insurance settlement expenses for inpatients of registered poor households, and to provide reference for rational use of medical insurance funds.MethodsThe registered poor inpatients in a tertiary hospital in Datong from January 1, 2018 to December 31, 2020 were included, and the K-Means method was used to cluster analyze the medical insurance settlement cost. ResultsThe patients were clustered into 5 categories: group 1: irrational referral patients; group 2: the patients cannot be diagnosed in primary medical institutions, and should be referred upward for definite diagnosis; group 3: the patients with common chronic diseases; group 4: the end stage patients with repeated hospitalization; group 5: the key group of medical insurance funds. The expense was mainly paid by basic medical insurance, critical disease insurance and medical insurance subsidy. There were statistically significant differences in age,gender, hospitalization times, number of diagnoses, severity of disease, surgery, length of stay, hospitalization cost and the medical insurance settlement cost of the five groups of patients (P<0.05). Conclusion The burden of disease of registered poor households was reduced by the medical security policy, there was the problem of unreasonable use of medical insurance funds. It was suggested that relevant institutions strengthen supervision over the use of medical insurance funds, standardize patients' medical treatment behaviors, and make concerted efforts to gradually establish a health poverty alleviation system that combines medical assistance, commercial insurance and social assistance.