湖北宜昌市夷陵区肺结核病单病种定额支付标准及控制

目的探讨夷陵区肺结核病单病种定额支付标准和可行性及控制,为进一步完善结核病防治政策提供参考依据。方法收集2014年1月至2015年9月间住院和门诊肺结核病患者医疗费结算信息,导入Execl进行患者类别、住院比例、医疗费分段、报销比例等信息统计分析,在此基础上提出定额支付标准假设与现行支付标准进行比较。结果 2014年1月至2015年9月,定点医院收治住院肺结核病患者444例,住院率占同期发现患者数的77.75%,总住院医疗费2 667 687.00元,医保农合报销1 600 815.30元,报销比例为60.00%,门诊结算肺结核病患者256人,总门诊医疗费用571 604.25元,医保农合报销457 283.40元,报销比例为80.00%。如将普通肺结核病患者住院比例提高到涂阳100.00%,涂阴30.00%以内,每例定额支付6 000.00元,患者自付比例保持涂阳10.00%,涂阴20.00%不变。门诊每例定额支付下降至每例3 000.00元,患者自付比例20.00%不变。与现行支付模式相比,总住院率降至34.23%,住院报销比例可提高到86.62%,门诊实际报销比例可提高到83.33%。患者负担明显降低,医保农合负担略有减轻,定点医院毛收入虽下降,但收入含金量明显提高。结论以公益为核心,转变医院管理理念,以工作质量为考核指标的绩效管理模式,才能实现真正的医保、医院、患者三方共赢局面。

Exploration on the standard and control of fixed single-disease payment of pulmonary tuberculosis in Yiling District,Yichang, Hubei Province

Objective To explore the standard, feasibility and control of fixed single-disease payment of pulmonary tuberculosis ( PTB ) for providing a reference to further improve the pulmonary tuberculosis prevention and control policy. Methods The settlement information of medical expenses of inpatients and outpatients with pulmonary tuberculosis was gathered from January 2014 to September 2015. The patients’ category, proportion of hospitalization, medical cost segmentation and reimbursement rate were put into Exel and statistically analyzed. Based on the above information the hypothetical standard of fixed single-disease payment was put forward and compared with the present payment criteria. Results From January 2014 to September 2015, 444 inpatients with pulmonary tuberculosis were admitted to the designated hospitals, and the hospitalization rate accounted for 77. 5% of patients found during the same period. The total medical expense was 2 667 687. 00 yuan, and 1 600 815. 3 yuan was paid by the rural cooperative medical insurance, with a 60% reimbursement rate. There were 256 outpatients with pulmonary tuberculosis. The total medical expense was 571 604. 25 yuan, and 457 283. 4yuan was paid by the rural cooperative medical insurance with a 80% reimbursement rate. If the hospitalization rate of smear-positive pulmonary tuberculosis patients was raised to 100%, and that of smear-negative was within 30%, and 6 000 yuan was paid per case by inpatients,with an unchanged individual self-paid ratio of 10% in smear-positive patients and 20% in smear-negative patients, and the fixed payment per case reduced to 3 000 yuan by outpatients with an unchanged individual self-paid ratio of 20%. As compared with the present payment pattern, the total hospitalization rate would reduce to 34. 23%, and the hospitalization reimbursement rate could increase to 86. 62%, and the actual reimbursement rate of outpatients could increase to 83. 33%. As a result, the burden of patients would somewhat decreased,and that of the rural cooperative medical insurance would also somewhat decreased. Although the gross income of designated hospitals would decline, the gold content would significantly improved. Conclusion These data suggested that a real tripartite win ( including medical insurance, hospitals and patients) could be realized only if the public welfare was taken as the core, the concepts of hospital management being changed, and the work quality was taken as an indicator for performance review.