河南省息县按病种综合支付改革实践与思考

医疗费用快速上涨促使了基于费用控制的支付方式的讨论,按病种付费是当前混合支付的重要选择之一。河南省息县按病种付费经过近10年的实践与探索,逐步形成了以政府为主导的总体购买、以病情为依据的定额支付、以质量为导向的绩效考核运行模式。按病种综合支付改革的核心是基于病情的路径分类与基于路径的质量管理。河南省在系统梳理按病种付费的原理下,结合息县的改革实践,明确了当前按病种综合支付改革的先决条件,探索了医保机构、政府部门、医院和医生职能的支撑与转换,在促进三医联动与分级诊疗的推进中也起到了积极作用。

Thoughts and Practice of DRGs-based Multi-Faceted Payment Reform in Xixian Henan Province

Discussions in terms of spending control-based payment methods were raised upon the rapid increase of medical expenditure in recent years, and Diagnosis Related Groups (DRGs) has been considered as one of the most promising choices among the blending payment mechanisms. In recent decade, an efficient DRGs-based payment model in Xi County had been established with potential of generalizability. In this model, three features were included: the medical services were purchased through government contracts, the reimbursement amount was pre-decided with classification and severity of diseases, and the performance evaluation was quality-oriented. The core strategy of the multi-faceted payment reform was that the payment was based on a clear classification of clinical pathways and quality-oriented process supervision. During the study, we firstly made a systematical analysis about the theory basis of DRGs; then we proposed the prerequisites for generalizing the Xi County multi-faceted payment model by revealing the context and current progress of Xi County reform; finally we discussed the transition of role concerning different stakeholders including the medical insurance administrators, the health administrators, the medical institutions and the providers. We conclude that the Xi County model may contribute to completing the comprehensive reforms in rural communities and promoting the hierarchical medical system.