DRG付费模式下的医保基金监管指标体系构建

构建全面实施按疾病诊断相关分组付费后的医保基金监管指标体系,有助于对医疗机构高套编码、缩减必要医疗服务、低标准入院、分解住院等非预期行为进行有效监管。文章根据结果导向、过程管理、全面客观的原则,基于医疗服务和按疾病诊断相关分组支付的事前、事中、事后3个环节构建按疾病诊断相关分组支付闭环下的医保基金监管指标体系。建议监管指标应适时调整,指标监管应与规则监管相结合,建立基于指标体系的智能监管系统,及时提示基金管理风险。

Construction of the Supervision Index System for Healthcare Insurance Fund under DRG Payment

Constructing the supervision index system for healtheare insurance fund under DRG payment could help to conduct effective supervision on the unexpected behaviors, such as high coding of diseases, reduction of necessary medical services, admission on low standards and decomposition of hospitalization. According to the principles of result orientation, process management, comprehensive and objective, it constructed the supervision index system for the healthcare insurance fund under the closed-loop of DRG payment based on three key links in medical services and DRG payment. It is suggested that regulatory indicators should be adjusted in a time, indicator regulation should be combined with rule regulation, and an intelligent monitoring system based on the indicator system should be established to prompt fund management risks in time.