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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。
Objective To investigate the standard and feasibility of fixed payment of tuberculosis in Yiling District and to provide a reference for further improvement of tuberculosis prevention and control policy. Methods We collected the medical expenses settlement information of inpatients and outpatients with pulmonary tuberculosis from January 2014 to September 2015 and imported them into the statistical analysis of information such as patient category, hospitalization rate, medical expenses segment and reimbursement ratio. On the basis of this, The payment standard hypothesis is compared with the current payment standard. Results From January 2014 to September 2015, 444 cases of hospitalized tuberculosis were admitted to designated hospitals. The hospitalization rate accounted for 77.75% of the total number of patients found in the same period, total hospitalization fee was 2 667 687.00 yuan, and reimbursement of Medicare insurance for rural cooperative medical care was 1 600 815.30 yuan. Reimbursement ratio of 60.00%, outpatient settlement of tuberculosis patients 256 people, the total out-patient medical expenses 571 604.25 yuan, 457 283.40 yuan medical insurance reimbursement, the reimbursement ratio of 80.00%. Such as ordinary tuberculosis patients hospitalized increased to smear 100.00%, Yin Yin 30.00% less than the amount of each case to pay 6,000.00 yuan, the proportion of patients with self-sufficiency to maintain smear 10.00%, Yin 20.00% unchanged. Each case of outpatient payment decreased to 3 000.00 yuan per patient, the patient pays 20.00% unchanged. Compared with the current payment model, the total hospitalization rate dropped to 34.23%, hospital reimbursement ratio can be increased to 86.62%, out-patient reimbursement ratio can be increased to 83.33%. The burden of patients was significantly reduced, the burden of Medicare and MCH slightly reduced, although the gross hospital receipts of designated hospitals decreased, but the income gold content increased obviously. Conclusion Taking the public welfare as the core, changing the hospital management concept and using the quality of work as the performance evaluation model can we achieve a win-win situation for the real medical insurance, hospitals and patients.