BackgroundIn 2018, an innovative case-based payment scheme called Diagnosis-Intervention Packet (DIP) was piloted in a large developed city in southern China. This study aimed to investigate the impact of the new payment method on total medical expenditure per case, length of stay (LOS), and in-hospital mortality rate across different hospitals.MethodsWe used the de-identified patient-level discharge data of hospitalized patients from 2016 to 2019 in our study city. The interrupted time series model was used to examine the impact of the DIP payment reform on inflation-adjusted total expenditure per case, LOS, and in-hospital mortality rate across different hospitals, which were stratified into different hospital ownerships (public and private) and hospital levels (tertiary, secondary, and primary).ResultsWe included 2.08 million and 2.98 million discharge cases of insured patients before and after the DIP payment reform, respectively. The DIP payment reform resulted in a significant increase of the monthly trend of adjusted total expenditure per case in public (1.1%, P = 0.000), tertiary (0.6%, P = 0.000), secondary (0.4%, P = 0.047) and primary hospitals (0.9%, P = 0.039). The monthly trend of LOS increased significantly in public (0.022 days, P = 0.041) and primary (0.235 days, P = 0.032) hospitals. The monthly trend of in-hospital mortality rate decreased significantly in private (0.083 percentage points, P = 0.002) and secondary (0.037 percentage points, P = 0.002) hospitals.ConclusionsWe conclude that implementing the DIP payment reform yields inconsistent consequences across different hospitals. DIP reform encouraged public hospitals and high-level hospitals to treat patients with higher illness severities and requiring high treatment intensity, resulting in a significant increase in total expenditure per case. The inconsistencies between public and private hospitals may be attributed to their different baseline levels prior to the reform and their different responses to the incentives created by the reform.

目的:总结加拿大卫生技术评估(HTA)应用于医保决策的经验,分析HTA在医保决策应用中存在的主要问题,为我国在医保决策中更好地发挥HTA的作用提供参考和借鉴.方法:查阅国内外相关文献,系统梳理了加拿大卫生技术评估的相关文献,提取了加拿大药物和卫生技术局和国际卫生技术评估机构官方网站上的相关信息.结果:加拿大HTA在国家、省级、机构多个层面设立并同时开展,证据生产及时、透明、规范.我国尚存在缺乏公开透明的药品评审机制,评审过程的效率低下,以及缺乏规范的医用耗材评价指标等问题.结论:借鉴加拿大HTA评估过程的公开透明性、HTA指南的严谨、科学性以及HTA体系的统一性等经验,我国仍需在基本药物评审中,确保利益相关者的透明度,制定指南来保证HTA质量评价标准,并形成互联互通地HTA全国网络体系,实现信息资源共享.

Abstract Context A patient classification-based payment system called diagnosis-intervention packet (DIP) was piloted in a large city in southeast China in 2018. Objective This study evaluates the impact of DIP payment reform on total costs, out-of-pocket (OOP) payments, length of stay (LOS), and quality of care in hospitalised patients of different age. Methods An interrupted time series model was employed to examine the monthly trend changes of outcome variables before and after the DIP reform in adult patients, who were stratified into a younger (18–64 years) and an older group (≥ 65 years), further stratified into young-old (65–79 years) and oldest-old (≥ 80 years) groups. Results The adjusted monthly trend of costs per case significantly increased in the older adults (0.5%, P = 0.002) and oldest-old group (0.6%, P = 0.015). The adjusted monthly trend of average LOS decreased in the younger and young-old groups (monthly slope change: -0.058 days, P = 0.035; -0.025 days, P = 0.024, respectively), and increased in the oldest-old group (monthly slope change: 0.107 days, P = 0.030) significantly. The changes of adjusted monthly trends of in-hospital mortality rate were not significant in all age groups. Conclusion Implementation of the DIP payment reform associated with increase in total costs per case in the older and oldest-old groups, and reduction in LOS in the younger and young-old groups without deteriorating quality of care.

目的 梳理上海市医疗保险(以下简称"医保")支付方式的演变过程及改革背景,理解其决策逻辑.方法 结合多源流分析与实施背景分析框架,分析上海医保支付改革形成的原因及特点.结果 各级政府均高度重视医保支付方式改革,为上海医保支付改革提供了政治支持.上海医保改革始终以政策问题为导向,早期面临基金失衡后采取总额预算管理,医院积极性不高便采取结余留用,基金效率低下而进行按疾病诊断相关分组/病种分值付费改革.上海"海派文化"中的"包容性"表现为"小步走、不停留"的改革理念,"精致性"表现为循证决策和数字化赋能的改革策略;上海较高的经济水平、较低的医保基金失衡风险,使其更多关注医院和患者利益,注重医疗服务质量,强调改革的连续性与一致性.结论 上海医保支付改革的演变是外部政策、当前问题、文化与经济环境等因素的综合产物.

目的 介绍上海市按疾病诊断相关分组(diagnosis related groups,DRG)付费改革的整体工作思路、分组策略与方法,及其细化落地过程中遇到的问题和主要做法,评价其分组效能,并提出未来调整策略,为其他试点城市提供相关经验.方法 查阅国内外相关文献,访谈上海市DRG改革相关专家,并基于2020年34家参与DRG测算的三级医院全口径病案人群,分析上海市DRG的分组方案效能情况.结果 上海市DRG的分组方案共有867个DRG细分组,达到国家医疗保障疾病诊断相关分组(China Healthcare Security Diagnosis Related Groups,CHS-DRG)所有26个主要诊断类别(major diagnostic category,MDC)、376个核心DRG(adjacent diagnosis related groups,ADRG)全覆盖要求.上海市DRG的分组效能,总体病例入组率为95.75％、变异系数(coefficient of variation,CV)<1.00组数占比为96.89％,总体方差减少系数(reduction in variance,RIV)值为0.76.结论 上海市DRG的分组方案基于《国家医疗保障疾病诊断相关分组(CHS-DRG)分组与付费技术规范》,综合考虑上海市病例实际特征,形成具有上海特色的DRG"七步法"分组路径,病例入组率高,且组内同质性和组间异质性结果较好,符合上海本地发展情况,并形成持续根据政策要求和实际情况进行动态调整机制,对其他地区分组方案具有一定的参考价值.