总额控制下按病组分值付费下某院神经内科费用成本与医保结算研究OACSTPCD

Objective To investigate the intrinsic relationship between inpatient costs,hospitalization expenses,and medical insurance settlement expenses in the neurology department of a 3-A-grade general hospital under the background of disease-based score payment in the total control of basic medical insurance in Chengdu,Sichuan Province,and to provide a reference for precise control of hospitalization expenses in medical institutions.Methods Based on the neurology-related disease cases in 2020 and the requirements of disease-based score payment in the total control of basic medical insurance in Chengdu,the cost,composition of hospitalization expenses,insurance payment standards,and profits of neurology-related disease groups were analyzed,and their interrelationships were summarized.Results Drug costs accounted for the largest proportion of medical costs in neurology-related disease groups(53.99%),followed by personnel expenses(21.92%).The composition of costs varied among different disease groups,and there were six relationships between insurance settlement standards,patients' hospitalization expenses,and hospital costs:insurance payment did not necessarily result in profit(scenario one),insurance non-payment did not necessarily result in loss(scenario two),insurance payment led to actual loss(scenario three),insurance non-payment resulted in actual profit(scenario four),insurance payment resulted in actual profit(scenario five),and insurance non-payment resulted in actual loss(scenario six).Conclusion Disease-based score payment in the total control of basic medical insurance in Chengdu can achieve overall cost control.Insurance settlement payment standard plays a guiding role in actual charges of disease groups and leverage the profits of medical institutions.The reform of insurance payment methods forces adjustments in the internal cost structure of departments,and attention should be paid to the value of medical staff labor and the reasonable control of drug consumption ratios.The competition effect between medical institutions and departments is increasing,and measures should be taken to avoid malignant competition leading to patient deferral.