目的: 基于辽宁省C市医保真实世界数据,分析DIP特例单议病例特征及改革实践,展开政策模拟验证,探讨政策优化调整措施。方法: 选取辽宁DIP付费具有代表性的地市C市2024年度464369例DIP病例大数据,根据拟定基于病种分值分段的高倍率病例遴选规则,测算出各档位特例单议病种例数并给出分布模拟结果,将该结果与该市原有特例单议政策进行比较。结果: 基于病种分值分段制定高倍率病例遴选规则体现了科学性,新规则提高了特例单议病例遴选结果覆盖范围的合理性,更加符合国家医保局对特例单议病例数量占比的要求,也便于对这些病例进行管理。本文的遴选方法,辽宁省DRG 2.0付费地区也有实施,实践证明了该方法的合理性与可行性。在按病种付费由2.0向3.0提升过程中,辽宁地市特例单议采用分段遴选的实践经验可以为全国其他地区提供有益参考。

Objective: Based on the real-world data of medical insurance in City C of Liaoning Province, this study analyzes the characteristics and reform practice of DIP special cases, conducts policy simulation verification, and explores policy optimization and adjustment measures. Methods: We selected 464369 DIP cases in City C, a representative city for DIP payment in Liaoning Province, in 2024. According to the proposed selection rules for high cost cases based on disease value segments, we calculated the number of special cases in each segment and provided distribution simulation results. These results were compared with the city's original special case negotiation policies. Results: The selection rules for high cost cases based on disease value segments demonstrated scientificity. The new rules improved the rationality of the coverage range of special case selection results, better met the requirements of the National Healthcare Security Administration for the proportion of special cases, and facilitated the management of these cases. The selection method in this study can also be implemented in the regions implementing DRG 2.0 version payment of Liaoning Province. Practical experience has proven the rationality and feasibility of this approach. During the transition from DIP 2.0 version to 3.0 version, the experience of segment-based selection of special cases in cities of Liaoning Province can provide useful references for other regions in China.