Background : Outpatient medical care payment play a pivotal role in the reform of medical insurance payment methods. With ongoing reforms in China, a variety of payment strategies, including capitation and the ambulatory patient groups (APG) point method, are being progressively implemented. Objective : This study aims to identify appropriate capitation calculation methods for chronic diseases in Beijing and to provide recommendations for implementing capitation payments reforms in the city. Methods : We focused on four prevalent chronic diseases—hypertension, diabetes, coronary heart disease, and stroke—and analyzed basic medical data and public health funding in Beijing's districts C and H as case studies. This research was aimed at developing a capitation calculation method tailored to these locales, determining payment standards for major chronic diseases in primary care clinics, and thus supporting the advancement of capitation reform for outpatient chronic diseases. Results : Using medical insurance data and public health funding data from 2017 to 2019, a top-down allocation was employed to determine the capitation payment standards in district H: 4,693.11 Yuan for hypertension, 6,597.70 Yuan for diabetes, 5,644.46 Yuan for coronary heart disease, and 6,437.78 Yuan for stroke. A bottom-up costing approach was used in district C, resulting in payment standards of 4,884.18 Yuan for hypertension, 5,960.63 Yuan for diabetes, 3,733.93 Yuan for coronary heart disease, and 3,886.66 Yuan for stroke. Conclusion : The outpatient costs associated with different chronic disease populations vary considerably. In view of maintaining equity in medical insurance and the fairness of capitation fees, it is imperative to apply risk adjustments to the benchmark capitation fee. Personalized services should be tailored to the diverse types and severities of chronic diseases. It is also crucial to provide customized basic medical and public health services to various chronic disease patients as part of the capitation payment reform for outpatient services. Additionally, enhancing the capabilities of community health services in managing chronic diseases, improving contracting percentages, and establishing effective incentive and evaluation mechanisms for general practitioners are essential for equitable distribution of surplus from capitation payments.

目的 通过梳理黑龙江省3个国家试点城市按病种分值付费(Diagnosis-Intervention Packet,DIP)政策基本运作模式与现状,总结做法与经验,为进一步深化DIP改革提供参考与借鉴.方法 基于利益相关者访谈和内容分析法,对3个DIP试点城市政策文件进行系统编码与分析.结果 黑龙江省3个DIP试点城市基于技术规范指导,积极创新本地化DIP管理办法,改革成效显著,次均住院费用、平均住院天数和平均自付金额均显著下降.改革过程中存在DIP辅助目录不健全、医院对DIP认知不足、医疗机构功能定位模糊等问题.结论 加强协议管理,进一步完善辅助DIP目录库和结算规则,不断提高对DIP的整体认知水平,倒逼医疗机构开展精细化管理,提升整体服务能力;促进医保、医疗间的协调联动,发挥DIP改革效能.

Objective:To explore the construction of medical insurance high-quality development index evaluation system in Beijing,and to provide a reference and basis for the objective evaluation and continuous improvement of the development effect of medical insurance in Beijing.Methods:The index system was determined through two rounds of Delphi consultation,based on preliminary literature research and expert discussions,taking into account the national and Beijing’s "14th Five-Year Plan" medical security development goals.Results:A system of indicators for assessing the quality development of medical security in Beijing,consisting of five primary indicators,14 secondary indicators and 21 tertiary indicators of equity,safety,wisdom,synergy and value and their weights,was formed.The positive coefficient of experts in both rounds of consultation was 100%,and the authority coefficient of experts was 0.70 and 0.79.Conclusion:The evaluation index system for high-quality development of medical insurance in Beijing is reasonable,scientific and reliable,which can serve as a model for the development and implementation of policies aimed at promoting high-quality medical insurance development.

目的 分析黑龙江省按病种分值付费(Diagnosis-Intervention Packet,DIP)政策实施效果,并提出相关建议.方法 运用统计描述和双重差分模型分析DIP政策对关键指标的影响情况.结果 DIP实际付费后平均住院天数、次均住院费用和平均自付金额均呈现下降趋势,病案书写质量有所提升,受多种复合因素影响,双重差分分析结果显示各指标差异无统计学意义(P＞0.05).结论 黑龙江省国家试点城市DIP改革取得了一定成效.随着DIP改革的推进,要持续完善病案书写质量,提高分组的合理性;进一步完善监管考核体系和加强信息系统建设,制定全省统一的DIP监测指标体系,不断提高DIP运行效果.

如何有效地约束医疗机构费用增长,合理利用医疗卫生资源,是全世界面临的挑战之一.在全球医疗卫生体制改革中,支付作为"控制柄"之一被寄予厚望.文章以门诊按人头付费支付方式改革为视角,通过对部分国家门诊按人头付费的实践与改革趋势进行分类和梳理,并基于我国国情提出建议,以期为我国门诊医保支付方式改革提供借鉴.

目的 分析三级公立医院职工动态能力水平,为三级公立医院培养动态能力、适应按病种分值付费(Diagno-sis-Intervention Packet,DIP)改革、推进高质量发展提供参考.方法 以国家DIP试点H省的J市和G市三级公立医院员工为调查对象,利用问卷调查和Likert5量表,发放909份问卷,共回收有效问卷796份,通过R 4.2.1 软件对数据进行清洗,对变量进行描述性分析、单因素分析与多元线性回归分析.结果 医院的动态能力处于一般水平,为(38.62±9.98)分,对DIP的感知识别能力和重构创造能力较弱,多元线性回归分析结果显示医院类型、职称、DIP下诊疗行为、医疗服务能力、医院对高质量发展关键点与运行关注点的认知特征是医院动态能力的影响因素(P＜0.05),对DIP知识的学习对动态能力的影响最大.结论 以实际付费提高医院职工对DIP改革的认知水平,重点培养对DIP知识学习能力,改变思维意识,规范诊疗服务行为,提高医疗服务能力,保证不同类型医院平稳渡过DIP改革的初期,以动态能力推动公立医院高质量发展.

目的:了解试点城市DIP实施情况并提出建议,为政策完善提供参考依据.方法:对黑龙江省J市和H市医院管理者和医务人员进行半结构式访谈和问卷调查,并引入史密斯政策执行过程模型,从不同维度分析其实施情况.结果:试点城市改革初具成效,结果显示60%的对象对政策了解程度较高并认为实施效果较好,但由于实际付费时间较短,也存在配套政策不完善和执行主体协作度不高等问题.结论:为保证DIP政策平稳有效运行,建议优化制度顶层设计,持续优化政策环境,加强部门联动,加大政策培训力度,提升医院管理者和医务人员的认知水平,增强其参与意愿.

Background The reimbursement of outpatient services is an essential part of the reform of medical insurance payment methods. With the comprehensive promotion of the reform on the medical insurance payment methods for inpatient services in China, the reform on insurance payment methods for outpatient services, such as capitation-based reimbursement and ambulatory patient groups (APG) point method, will gradually be put on the agenda. Objective To explore a capitation-based reimbursement scheme for chronic diseases applicable to Beijing based on an analysis of capitation-based reimbursement implemented in different countries and regions and the current situation of chronic disease management in Beijing, to provide a reference for implementing the capitation-based reimbursement reform for chronic diseases in Beijing. Methods This study used information related to essential medical services, reimbursement by health insurance, and essential public health service funds in Beijing's C and H districts. Then through an analysis of the information, the calculation method for capitation-based reimbursement standard for four common chronic diseases (hypertension, diabetes, coronary heart disease and stroke were selected in this study) applicable in the districts was designed to calculate the capitation-based reimbursement standard for major chronic diseases in primary outpatient clinics, providing a reference for promoting the capitation reform for chronic diseases in outpatient clinics. Results By analyzing the above-mentioned information in 2017—2019, the capitation-based reimbursement standard was 4 693.11 yuan/person for hypertension, 6 597.70 yuan/person for diabetes, 5 644.46 yuan/person for coronary heart disease, and 6 437.78 yuan/person for stroke in H district calculated using the bottom-up costing, and was 4 884.18 yuan/person for hypertension, 5 960.63 yuan/person for diabetes, 3 733.93 yuan/person for coronary heart disease, and 3 886.66 yuan/person for stroke in C district calculated using the top-down estimating. Conclusion In calculating the capitation-based reimbursement standard, as different chronic disease patient groups have different outpatient costs, considering the equity of medical insurance reimbursement and the rationality of capitation-based reimbursement, it is necessary to adjust the risk of the benchmark capitation, and develop personalized service packages for different types and severity of chronic diseases. In the promotion of capitation payment for chronic disease patients, it is necessary to provide personalized essential medical service and public health service packages for patients with different chronic diseases, further improve the chronic disease management capacity of community health institutions to improve the contracting rate and establish an effective incentive and assessment mechanism for general practitioners to rationally allocate capitation balance.

目的:基于医保新发展理念,以国家宏观政策为导向,结合北京市医疗保障改革工作重点,构建医保高质量发展评价指标体系,评价2018-2021 年北京市医疗保障高质量发展状况.方法:运用描述性分析结合灰色综合评价方法,从参保公平、管理服务、基金监管、社会协同、运行效果五个维度进行分析.结果:整体上,北京市2018-2021 年医保高质量发展水平呈现稳步提升趋势,各维度指标取值逐步向最优值靠近.结论:评价指标体系和评价方法具有科学性与适用性.北京市医保发展水平不断提高,但发展不稳定和不平衡问题显现;医保制度体现一定公平性,应保尽保与重复参保问题仍存在;医保基金平稳可持续运行,制度间存在筹资待遇差距;医保基金监管机制逐步健全,监管方式亟需创新优化.

信息化建设是公立医院高质量发展的重要支撑和保障,而投入问题是影响公立医院信息化建设最主要和最迫切的因素,如何建立完善且有效的投入机制成为信息化建设中亟需解决的关键问题.本研究从政策、资金和人才投入3个方面阐述了我国公立医院信息化建设投入的现状,分析可能存在的问题,并结合部分发达国家医院信息化建设过程中的经验教训,为完善我国公立医院信息化建设投入机制提供政策建议,以期推动医院信息化建设高质量发展.

Objective To study the current treatment of congenital diseases in a 3A grade children’s hospital in Beijing. The structure and costs of congenital diseases in children are analyzed from the perspective of CHS-DRG to provide the basis for improving children’s health insurance and medical insurance payment. Methods The first page of medical records and settlement data of medical insurance of patients with congenital diseases under the Beijing medical insurance in 2021 were collected in this hospital. The reimbursement of patients with congenital diseases was analyzed. The distribution of congenital diseases was sorted out according to the DRG classification. And the differences in medical expenses of patients of different ages within the same DRG group were calculated. Results In 2021,congenital diseases were included in the reimbursement of basic medical insurance in Beijing, and the actual reimbursement ratio reached 59.41%. Most inpatients with congenital diseases were male and preschool children, and most were treated with surgery. The CMI value was 1.09. The treatment was more difficult and the cost was higher than the average level. MD1（testicular surgery）,DC2（other minor surgeries on ears）and FD3（congenital heart disease intervention）were predominant according to CHS-DRG classification scheme. The treatment cost of patients under 6 years old in the same DRG group was higher than that of patients over 6 years old. Conclusions The reimbursement of medical insurance for children with congenital diseases has been improved. It is necessary to further optimize the classification scheme based on the characteristics of congenital diseases, and refine the payment rules based on the cost distribution, so as to further reflect the technical value of pediatric diagnosis and treatment.

目的 基于内外因素论,对北京市精神疾病领域科研项目资助的影响因素进行调查,旨在为提高该疾病领域科研项目资助率提供依据.方法 结合文献检索法、访谈法和问卷调查法,对北京市3家精神疾病专科医院科研人员和科研管理人员进行科研项目资助率影响因素调研及对策分析,采用描述性分析、方差分析和多重响应分析方法进行数据统计分析.结果 2016-2020年,首都医科大学附属北京安定医院共申报科研项目378项,获批科研项目149项(39.42％).影响科研项目资助的内部因素包括申报人团队、申报书质量,外部因素包括所属平台、所属学科领域.与申报瓶颈相关的内部因素中申报人及团队、申报书质量及外部因素中所属平台这3个节点占总节点数的83.3％.结论 影响科研项目资助的因素包括内部因素和外部因素,申报动机是重要因素之一.强化申报动机,夯实研究基础,合理设置科研绩效考核机制是提高当前精神疾病领域科研项目资助率的重要措施.

目的:调查医保从业人员的教育和专业背景等情况,分析医保从业人员对医保支付方式的知晓水平和影响因素,为提高医保从业人员的专业能力提出对策和建议.方法:选取不同地区医保从业人员,于2021年进行线上问卷调查并收集数据,主要包括人口学特征、医保支付方式知晓情况、工作投入情况.采用SPSS23.0统计软件进行秩和检验、Spearman相关性分析和无序多分类Logistic回归分析.结果:共回收有效问卷280份,调查对象中40岁以下的医保从业人员占比55.7％,68.6％的医保从业人员有本科及以上学历,65.4％有10年及以上工作经验,7.9％是保险类专业背景,44.3％是医护类专业背景.Logistic回归分析结果显示,影响医保从业人员对医保支付方式知晓情况的因素有工作年限、职称、工作机构、所在地区.结论:加强医保从业人员的培训和继续教育力度,加快建立职称晋升制度,建设专业医保人才队伍,促进医保支付方式改革高效运行.

目的:了解北京市老年人群的医疗保障利用与评价情况,并分析其影响因素,为完善医疗保障制度、实现健康老龄化提供决策依据.方法:通过对在北京市6家不同等级医疗机构就诊的老年人进行问卷调查,获得老年人参保、医保使用、就医行为以及对医保满意度评价情况,并使用卡方检验和多因素logistic回归分析老年人群医保满意度影响因素.结果:被调查的老年人参保率和医保使用率均较高,在报销方式上更倾向于人工缴费窗口.职工医保老年人就近就诊符合率较低.对于医保异地报销表示很不满意和不了解的老年人较多.健康状况水平、职工医疗保险和居民医疗保险能够显著影响老年人对北京市医保服务的满意度.结论:建议进一步提升老年人参保率和医保使用率,协同推进分级诊疗与医保制度配套,充分发挥政策叠加效应,促进医疗资源的合理配置与利用,并继续普及和完善医保异地就医制度,提升居民医保的待遇水平,促进职工医保与居民医保的融合,最终推进医保高质量发展和健康老龄化.

目的 了解按病种分值付费(Diagnosis-Intervention Packet,DIP)后,三级公立医院人员对DIP的认知水平与学习培训情况,评价对DIP的学习能力,为更好地推进改革提供建议.方法 选取第一批国家DIP试点H省的J市与G市的三级公立医院工作人员,进行问卷调查,共回收有效问卷796份.结果 三级公立医院的医务人员与行政管理人员对DIP的认知水平有了提高,学习和培训途径较为丰富.但整体上对DIP学习能力处于一般水平,探索性学习能力(17.84分)弱于利用性学习能力(19.49分),行政管理人员的对DIP的学习能力强于医务人员(P= 0.02),认为DIP能够提高医疗服务能力的人学习能力更强(P= 0.03),具备一定DIP知识的工作人员对DIP的学习能力反而不高(P＜0.001).结论 在下一阶段,重点提高医务人员对DIP的认知水平,采用差异化培训,以实践促进对DIP认知的再提高,重视培养与利用DIP双元学习能力,提升医院可持续竞争优势.同步跟进基于DIP的医院绩效改革与全民健康信息化平台建设,助力医院高质量发展.

为完善我国慢性病门诊医疗保障制度,提高慢性病患者医疗保障待遇,基于正义理论并使用内容分析法梳理了8个医保支付方式改革试点地区典型城市现行慢性病门诊医疗保障政策.从保障范围、支付方式等方面进行描述并比较分析,总结现行慢性病政策的优缺点,并针对未来改进方向给出建议,以构建更合理的慢性病门诊医疗保障体系.

"十四五"时期,公立医院医疗服务能力与医保管理能力成为迈向高质量发展的关键.医保支付方式改革有效地将医疗服务与医保基金相结合,成为推动高质量发展的重要动力源.为了使公立医院适应动态复杂的改革环境,作者阐述了医保支付方式改革的核心内涵,深入分析了公立医院改革过程中的机遇与挑战.从动态能力与组态视角,融合青岛试点地区实践探索,深入分析医保支付方式助力公立医院高质量发展的路径框架.

目的:通过调查北京市城镇职工参保者个人账户的使用情况和改革意愿,为确保职工医保门诊共济保障工作顺利开展提供参考建议.方法:开展问卷调查,采用SPSS 26.0对数据进行描述性分析和卡方检验,根据统计分析结果,获取不同特征调查对象对个人账户改革的看法和建议.结果:北京市个人账户结余远低于全国水平;受访者的年龄、受教育程度、就业状况和慢性病诊断情况在一定程度上影响其对个人账户的使用情况和支付改革意愿.结论:北京市改革个人账户,进行专款专用,得到了绝大多数参保人的认可,建议持续完善相关配套政策措施,保障参保职工的基本权益.

目的:通过分析医务人员与患者对骗保行为的认知情况、原因及防范措施,为完善医保基金监管制度提供建议.方法:在理论与文献基础上,设计医务人员与患者调查问卷,选取北京某综合性三甲医院进行现场调研,共收回300份有效问卷,分析医务人员与患者的骗保认知差异.结果:医患双方对骗保行为缺乏认知,经归类分析后,骗保行为包括主观故意骗保和客观过失骗保,骗保原因是认知缺乏与决策偏差,罚款、取消定点医疗机构资格是医患双方对骗保防范措施的共同看法.结论:加强骗保知识宣传教育,提高医患双方对骗保行为的认知度,减少客观过失骗保行为;以法律为准绳,严厉打击主观故意骗保行为;利用信息化统一平台,建立智慧医保,提高医保监管效能.

目的:通过调查医务人员CHS-DRG认知程度,为后续推进CHS-DRG提供参考建议.方法:开展问卷调查,利用Excel 2010进行描述性分析,SPSS 16.0软件进行卡方、秩和检验及多元有序logistic回归分析.结果:医务人员CHS-DRG相关知识的认知水平有待提高;已试点地区的认知水平表现不理想,新试点地区中的国家级试点地区比省级试点地区CHS-DRG认知水平更高.结论:需通过加强培训、优化工作流程及设立奖励机制改善医务人员的认知水平.