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卫生经济研究[ISSN:1004-7778/CN:33-1056/F]

卷:

42

期数:

2025年02期

页码:

77-80

栏目:

医院管理

出版日期:

2025-02-06

文章信息/Info

Title:

Study on Medical Insurance Management Model in Hospitals under DRG Payment

作者:

王卉晓¹; 叶腾飞²; 张 琳³

1.安徽省卫生健康委员会， 安徽 合肥 230022
2.安徽省第二人民医院，安徽 合肥 230011
3.合肥工业大学管理学院，安徽 合肥 230009

Author(s):

WANG Huixiao;  YE Tengfei;  ZHANG Lin

Anhui Provincial Health Commission, Hefei Anhui 230022, China

关键词:

DRG支付; 医院; 医保管理; “六边形”模式

Keywords:

DRG payment;  hospital;  health insurance management;  "hexagonal" model

分类号:

R197.322

文献标志码:

A

摘要:

在DRG支付背景下，样本医院实行医保管理“六边形”模式：基于医院文化，制定DRG管理规则并授权，构建纵横结合的管理体系，采取集成方法开展对DRG入组、拒付反馈、运营管理的培训指导，并建立奖惩机制。结果显示：实行“六边形”模式后，样本医院的住院次均费用、西药占比、耗材占比降低，住院床日缩短，住院人次增加，CMI值提高，医疗服务能力和效率显著提升；DRG亏损得到控制但仍在持续，应强化风险管理意识，灵活应用“六边形”模式，完善DRG付费政策。

Abstract:

Under the background of DRG payment, the sample hospital implements the "hexagonal" model of medical insurance management. Based on the guidance of hospital culture, the hospital formulates DRG management rules and authorization, builds a vertical and horizontal management system, adopts an integrated approach to training and guidance on DRG entry, refusal feedback, operation and management, and establishes a mechanism of rewards and punishments. The results show that after the implementation of the "hexagonal" model, the average cost of hospitalization, the proportion of western medicines, and the proportion of consumables in the sample hospital have been reduced, the length of hospital beds has shortened, the number of hospitalizations has increased, the CMI value has improved, and the medical service capacity and efficiency have significantly improved. The DRG losses have been controlled but are still persistent, which indicates that the DRG payment policy should be improved by strengthening the awareness of risk management, and flexibly applying the "hexagonal" model.

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更新日期/Last Update: 2025-02-06