摘要
DRG/DIP付费会产生政策改革的“引致效应”,医疗机构基于利益动机容易出现应对新型支付方式的异化行为,导致医保基金监管面临严峻挑战。本文从数据质控端、医疗行为端和医院管理端三个维度,厘清了DRG/DIP付费下的异化行为内涵及其外延表现,提出了进一步加强医保基金精准监管和靶向监管的政策建议。
DRG/DIP payment will have a "induced effect" of reform, because medical institutions will respond to the new payment method based on profit motive and trigger alienation behaviour, which could result in a serious regulatory situation for the medical insurance fund. This paper clarifies the connotation of DRG/DIP payment alienation behavior and their external manifestations from three dimensions of data quality control, medical behavior and hospital management, and accordingly proposes policy recommendations on how to conduct precise and targeted regulation.
出处
《中国医疗保险》
2023年第2期27-34,共8页
China Health Insurance
基金
国家自然科学基金青年科学基金项目“价值医保视域下DRG付费改革的效果评价及政策优化研究”(72004235)
首都医科大学国家医疗保障研究院开放性课题“基于DRG/DIP支付方式改革的基金监管方式创新研究”(YB2022B16)。
关键词
DRG/DIP付费
异化行为
欺诈骗保
医保基金监管
DRG/DIP payment
alienation behavior
insurance fraud
the medical insurance fund regulation
