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北京按病种分组付费(BJ-DRG-pps)试点自2011年11月开始,经过5年六家医院的试点基本保证平稳运行,试点内容包括:医保费用结算流程、病案首页合格率、费用结构调整及最重要的政策推广,基本达到了试点预期的目标。然而,五年的实践工作中,无论从医疗机构还是经办机构方面逐渐暴露出许多深层次问题,本文从医疗机构医保管理的角度出发,尝试通过一些数据和事实的分析,深层剖析北京基本医疗保险DRGs付费试点后在费用和管理方面带来的新挑战和机遇,并对通过优化结算流程提高结算率、价格滞后造成的费用结构失衡、定额标准调整机制不健全及配套政策急需细化问题产生原因提出思考建议。
Beijing BJ-DRG-PPS pilot Since November 2011, the Pilot Project of six hospitals in China has been running smoothly for five years. The pilot programs include: medical insurance fee settlement process, first pass rate of medical record, fee structure Adjustment and the most important policy promotion basically reached the target of the pilot project. However, in the practice of five years, many deep-seated problems gradually emerge from the medical institutions and the handling agencies. From the perspective of the medical insurance management of medical institutions, this paper tries to analyze the basic medical treatment of Beijing through some data and factual analysis Insurance DRGs will bring new challenges and opportunities in terms of costs and management after paying for pilot projects, and will also result in an imbalance in the cost structure caused by the settlement rate optimization and price hysteresis due to the optimized settlement process, the unsound standardization mechanism and the urgent need for detailed policies for supporting policies Reason for thinking and suggestions.