目的: DIP支付方式对各类抗肿瘤药物采用相同的支付标准,未能有针对性地体现各类药物的价值。本研究以肺癌药物为例,根据药物机理及创新程度,分析不同类别抗肿瘤药物的成本差异,探讨DIP肿瘤病种支付标准精细化调整的方法学。方法: 选取广东省广州市两家三甲医院2018年—2020年肺癌住院患者作为样本,分析使用不同类别药物的住院费用并对四个治疗组进行两两比较,将住院费用具有统计学差异且差异百分比大于设定阈值的治疗组细分为不同病组进行支付,对比分析细分前后对医保基金预算的影响。结果: 免疫治疗联合化疗组、单用免疫治疗组、单用靶向治疗组及单用化疗组的平均住院费用分别为每例26379元、18832元、16345元、13753元,四个治疗组的总住院费用均存在统计学差异且差异百分比高于基数组20%。对细分病组进行医保基金预算影响分析发现,由于节省了大量不必要的化疗支出,医保基金支出总体下降或持平。结论: 基于真实世界数据的DIP肿瘤病种支付标准动态调整可以支持医保精细化管理、促进创新国谈药医院准入和临床合理用药。

Objective: Under the DIP payment schemes, all anti-tumor drugs are paid using the same payment standard, which is insufficient to reasonably reflect the value of various drugs. Using lung cancer drugs as an example, this study examined the cost differences of anti-tumor drugs based on drug mechanisms and innovation levels, and explored the methodology for adjusting the payment standards for DIP cancer diseases. Methods: Lung cancer patients admitted to two tertiary hospitals in Guangzhou from 2018 to 2020 were selected. The costs of different types of drugs were analyzed and the four treatment groups were compared pairwise. We divided the treatment groups with statistical differences in hospitalization expenses and a percentage difference greater than the given threshold into different disease groups for payment, and compared the impact of subdivision on the medical insurance fund budget. Results: The average hospitalization cost for the immunotherapy combined with chemotherapy group, the mono-immunotherapy group, the mono-targeted therapy group and the mono-chemotherapy group were 26379 yuan, 18832 yuan, 16345 yuan, 13753 yuan per case, respectively. There were statistical differences in the total hospitalization expenses among the four treatment groups, and the percentage difference was 20% higher than the base group. The budget impact analysis indicated further segmentation of disease groups could lead to overall decrease or stability of medical insurance funds due to reduction in expenses associated with a large amount of unnecessary chemotherapy. Conclusion: Dynamic adjustment of payment standard based on real world data could support refined management of medical insurance, increase hospital access of innovative negotiated drugs, and promote clinical rational drug use.