DRG付费模式下的医保基金监管指标体系构建.docxVIP

□ 医疗保障?MEDICALINSURANCE 《中国卫生经济》第41卷 第9期（总第475期）2022年9月 DRG付费模式下的医保基金监管指标体系构建 崔 斌① , 程 斌② , 朱兆芳② , 苏 岱③ , 李 鸣⑥ , 孙 谦④ , 杨 琳⑤ 摘 要 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。 关键词 按疾病诊断相关分组；医保支付方式改革；医保基金监管；监管指标体系 中图分类号 R1-9；F197 文献标志码 B 文章编号 1003-0743（2022）09-0029-04 Construction Construction of the Supervision Index System for Healthcare Insurance Fund under DRG Payment/CUIBin, CHENG Bin, ZHUZhao-fang, et al.//Chinese Health Economics, 2022,41(9):29-32 Abstract Constructing the supervision index system for healthcare insurance fund under DRGpayment could help to conduct efG fective 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, compreG hensive 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 DRGpayment. 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. Keywords Diagnosis Related Group; the reform of medical insurance payment system; supervision for healthcare insurance fund; supervision index system First-author’s address School of Public Health, Peking University, Beijing, 100191, China Corresponding author ZHUZhao-fang, E-mail:zhuzhaofang@nhei.cn 当前， 实施按疾病诊断相关分组（Diagnosis Related Groups， DRG）付费是医保住院支付方式改革的难点。 随着DRG改革的全面推进， 医疗机构除了可推动医疗 服务流程和相关医务工作者的行为向规范化转