【摘要】：目的:建立基于風(fēng)險(xiǎn)調(diào)整的門診統(tǒng)籌按人頭付費(fèi)支付標(biāo)準(zhǔn)。方法:利用深圳市社會(huì)醫(yī)療保險(xiǎn)信息系統(tǒng)2014—2015年的數(shù)據(jù),采用描述性統(tǒng)計(jì)對(duì)參保人員參保情況和就診情況進(jìn)行描述,采用兩部模型進(jìn)行風(fēng)險(xiǎn)調(diào)整模型建模估計(jì)。結(jié)果:參保人群月門診人均總費(fèi)用預(yù)測(cè)值為6.17元,同時(shí)篩選出年齡、性別、醫(yī)保參保檔次、是否慢病或大病患者4個(gè)因素作為風(fēng)險(xiǎn)調(diào)整因素,據(jù)此確立了52個(gè)不同人群組別的人頭費(fèi)用標(biāo)準(zhǔn)。結(jié)論:根據(jù)參保者的患病風(fēng)險(xiǎn)和預(yù)期衛(wèi)生服務(wù)利用對(duì)按人頭付費(fèi)進(jìn)行風(fēng)險(xiǎn)調(diào)整,建立相對(duì)可操作的人頭費(fèi)用調(diào)整方法,為各地開展按人頭付費(fèi)改革和后續(xù)進(jìn)一步研究提供參考。
[Abstract]:Objective: to establish a head-to-head payment standard for outpatients based on risk adjustment. Methods: using the data of Shenzhen Social Medical Insurance Information system from 2014 to 2015, descriptive statistics were used to describe the insurance situation and medical treatment, and two models were used to model and estimate the risk adjustment model. Results: the average monthly total cost of outpatients was estimated to be 6.17 yuan, and age, sex, grade of insurance coverage, slow disease or serious illness were selected as risk adjustment factors, and the risk adjustment factors included age, sex, medical insurance coverage grade, slow disease or serious illness. Based on this, the head cost criteria for 52 different population groups were established. Conclusion: according to the risk of health service and the risk adjustment of head-to-head payment, a relatively operational method of head-cost adjustment is established, which can provide reference for the reform of head-to-head payment and the further study in the future.
【作者單位】： 華中科技大學(xué)同濟(jì)醫(yī)學(xué)院醫(yī)藥衛(wèi)生管理學(xué)院;南方醫(yī)科大學(xué)南方醫(yī)院;華中科技大學(xué)同濟(jì)醫(yī)學(xué)院附屬同濟(jì)醫(yī)院;
【基金】：國(guó)家自然科學(xué)基金項(xiàng)目(71273100) 華中科技大學(xué)“中央高�；究蒲袠I(yè)務(wù)費(fèi)”(2016AB022)
【分類號(hào)】：F842.684;R197.1

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