[1]陈 洁,许晨虹,林振威.基于门诊病例分组的费用标准测定及门诊支付改革研究[J].卫生经济研究,2024,41(08):49-52.
　CHEN Jie,XU Chenhong,LIN Zhenwei.Study on the Measurement of Cost Standards and the Reform of Outpatient Payment based on Outpatient Case Grouping[J].Journal Press of Health Economics Research,2024,41(08):49-52.
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基于门诊病例分组的费用标准测定及门诊支付改革研究
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卫生经济研究[ISSN:1004-7778/CN:33-1056/F]

卷:
41
期数:
2024年08期
页码:
49-52
栏目:
医疗保障
出版日期:
2024-08-01

文章信息/Info

Title:
Study on the Measurement of Cost Standards and the Reform of Outpatient Payment based on Outpatient Case Grouping
作者:
陈 洁1; 2; 许晨虹1; 林振威1
1.浙江省肿瘤医院，浙江 杭州 310022
2.浙江省省级医院管理中心，浙江 杭州 310002
Author(s):
CHEN Jie;  XU Chenhong;  LIN Zhenwei
Zhejiang Cancer Hospital, Hangzhou Zhejiang 310022, China
关键词:
门诊病例分组; 门诊费用; 决策树; 门诊医保支付改革
Keywords:
outpatient case grouping;  outpatient cost;  decision tree;  outpatient medical insurance payment reform
分类号:
R19
文献标志码:
A
摘要:
目的：基于决策树原理测定门诊费用标准，为门诊医保支付改革提供定价参考。方法：采集2023年1—6月共41 371份肺恶性肿瘤门诊病例数据，利用决策树模型进行门诊病例分组并测定标准费用，在分类基础上对超线费用进行分析。结果：“是否用药”“是否治疗”“是否检验”等5个影响因素纳入分组规则，共形成8个门诊病例组合；研究得出的标准总费用对实际总费用的解释效果达到71.07%，10.76%的线外病例消耗了24.23%的医疗资源。结论：推进门诊医保支付改革，控制门诊医疗费用过快增长，从而完善医保基金长效平衡机制，实现医疗、医保、医药高质量协同发展。
Abstract:
Objective To determine the outpatient cost standard based on the principle of decision tree, and provide pricing reference for outpatient medical insurance payment reform. Methods A total of 41 371 outpatient cases of pulmonary malignant tumors were collected from January to June 2023, and the decision tree model was used to group the outpatient cases and determine the standard cost, and the over-the-line cost was analyzed on the basis of classification. Results Five influencing factors such as "whether to use drugs", "whether to treat", and "whether to test" were included in the grouping rules, resulting in a total of 8 outpatient case combinations. The explanatory effect of the standard total cost obtained from the study on the actual total cost reached 71.07%, and 10.76% of the out-of-line cases consumed 24.23% of the medical resources. Conclusion It is necessary to promote the outpatient medical insurance payment reform, and control the excessive growth of outpatient medical costs, in order to improve the long-term balance mechanism of the medical insurance fund and realize the high-quality synergistic development of medical care, medical insurance and medicine.

参考文献/References:

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[2] 李学冬，刘玉华，杨振儒，等.门诊患者分组对我国医疗保险支付制度的启示[J].中华医院管理杂志，2020，36（06）：477-479．
[3] 金萍妹，华伟，陈洁，等.基于疾病诊断相关组法制定单病种住院费用标准的研究[J].中国卫生经济，2019，36（02）：26-28.
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更新日期/Last Update: 2024-08-01