分析DIP特例单议病例特征及改革实践,探讨政策优化措施。选取样本城市2022年特例单议病例2926例,运用分位数回归分析方法探究其费用影响因素。结果显示,特例单议病例以三级医院、高龄、超长住院、多手术/学科治疗、保守组病种为主,机构等级、住院时间、单议类型、转科、离院方式、病种属性等多因素共同影响特例单议病例的住院费用。特例单议旨在通过对特殊病例的合理补偿提高支付的科学性和精准性,配套协商谈判、监管考核等机制,助推医保精细化管理。建议合理确定特例单议的适用条件,健全核心要素调整机制,完善配套政策,打好DIP改革的组合拳。

The characteristics and reform practice of special cases under DIP payment were analyzed, and policy optimization measures were discussed. A total of 2926 special cases in 2022 was selected from the sample cities, and quantile regression analysis method was used to explore the influencing factors of their costs. The results showed that the characteristics of the special cases were mainly tertiary hospitals, senile patients, long hospitalization, multi-operation or multi-discipline treatment, and conservative group diseases. Multiple factors such as institution level, length of hospitalization, negotiation type, transfer of department, discharge method, and disease attributes jointly affect the hospitalization costs of special cases. The special case negotiation promotes the scientificity and accuracy of payment through reasonable compensation for special cases, and supporting mechanism such as negotiation and supervision assessment promotes the refined management of medical insurance. It is suggested that the conditions for the application of special cases should be reasonably determined, the adjustment mechanism for core elements should be improved, supporting policies should be launched, and the combination of reform should be implemented.