分级诊疗背景下住院患者流向及费用分析 ——以安徽省城乡居民为例

基于安徽省级医保信息平台获取36个县域城乡居民医保住院患者基础信息,统计描述住院患者的住院流向、住院费用及医保补偿基金分布等。2016—2019年,县域外住院人次占比为28.38%~30.79%;住院总费用、医保补偿基金和住院次均费用的年均增速分别为6.76%、11.34%和4.79%;县域外住院总费用、医保补偿基金占比最大且逐年增加;住院补偿比为53.78%~61.42%,县域外住院补偿比逐年增加。从城乡居民医保住院患者就诊流向来看,分级诊疗效果尚未显现,医保补偿基金流向县域外的趋势未得到有效控制。应通过加强紧密型医共体建设,提高基层服务能力等方面采取措施,支撑分级诊疗制度的落地。

Analysis of inpatient flow and cost under the background of graded diagnosis and treatment: A case study of urban and rural residents in Anhui Province

Basic information of medical insurance inpatients for urban and rural residents in 36 counties was obtained based on the provincial medical insurance information platform, and the flow of inpatients, the cost of inpatients and the distribution of medical insurance compensation fund were statistically described. From 2016 to 2019, the proportion of hospitalizations outside the county was 28.38%-30.79%; The average annual growth rates of total hospitalization cost, medical insurance compensation fund and average hospitalization cost were 6.76%, 11.34% and 4.79%, respectively. The proportion of total hospitalization expenses and medical insurance compensation funds outside the county increased year by year. The inpatient compensation ratio was 53.78% ~ 61.42%, and the inpatient compensation ratio outside the county increased year by year. From the perspective of the flow of inpatients of medical insurance for urban and rural residents, the effect of graded diagnosis and treatment has not yet been shown, and the trend of medical insurance compensation fund flowing outside the county area has not been effectively controlled. Measures should be taken to support the implementation of the hierarchical diagnosis and treatment system by strengthening the construction of the close-knit medical community and improving the service capacity at the grassroots level.