通讯作者: 妥宏武, tuohongwu@163.com

DOI：10.12201/bmr.202502.00051

Analysis on the Impact of Medical Insurance Reform and Innovation on Outpatient and Inpatient Services: Taking Jinhua as an Example

• 摘要：目的：实证分析医保支付方式改革冲击下门诊服务与住院服务之间的关系，验证改革效果。方法：利用金华市8个区县2020-2022年医疗服务与医保支付数据；构建门诊住院固定效应模型，分析医保支付改革、门诊服务对住院服务的影响作用。结果：DRG支付对住院人次有显著的正向影响，对职工医保住院费用有显著的负向影响；“人头打包+APG”门诊支付对住院人次有显著的负向影响，对居民医保住院费用有显著的负向影响；门诊支付与门诊人次的交互项对职工医保住院人次有显著的负向影响，门诊支付与门诊费用的交互项对整体和职工住院费用有显著的负向影响。结论：DRG支付改革带来了住院人次的上升，降低了职工医保住院费用；门诊“人头打包+APG”支付改革起到了降低住院人次的作用，并降低了居民医保住院费用，减缓了门诊与住院之间的互补效应。

  关键词： 门诊统筹；门诊APG点数法；人头打包付费；组合政策; ; ; 

   

  Abstract: Objective: This study empirically analyzes the relationship between outpatient and inpatient services under the impact of healthcare payment reform, and evaluates the effects of the reform. Methods: Data from healthcare services and basic medical insurance payments in eight districts of Jinhua City from 2020 to 2022 were used. A fixed-effects model for outpatient and inpatient services was constructed to analyze the impact of healthcare payment reforms and outpatient services on inpatient services. Results: The DRG-based payment had a significant positive effect on inpatient visits and a significant negative effect on employee basic medical insurance inpatient costs. The capitation + APG outpatient payment policy had a significant negative effect on inpatient visits and a significant negative effect on residents basic medical insurance inpatient costs. The interaction between outpatient payment and outpatient visits had a significant negative effect on employee basic medical insurance inpatient visits, while the interaction between outpatient payment and outpatient costs had a significant negative effect on both overall and employee inpatient costs. Conclusion: The DRG payment reform led to an increase in inpatient visits and a reduction in employee basic medical insurance inpatient costs. The outpatient capitation + APG payment reform reduced inpatient visits and lowered residents basic medical insurance inpatient costs, thereby slowing down the complementary effect between outpatient and inpatient services.

  Key words: Outpatient coordination; Ambulatory patient groups; Capitation bundled payment; Policy package

  提交时间：2025-02-24

  版权声明：作者本人独立拥有该论文的版权，预印本系统仅拥有论文的永久保存权利。任何人未经允许不得重复使用。
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• 序号	提交日期	编号	操作
  1	2024-10-14	bmr.202502.00051V1	下载

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