中医民族医医保支付方式改革现状及影响因素分析&#x02014;&#x02014;以新疆维吾尔自治区为例

王宁宁; 朱晓晨; 郑洁楠; 海沙尔江&#x000b7;吾守尔; 马凯丽; 韩晟; 艾则孜江&#x000b7;艾尔肯

doi:10.19546/j.issn.1674-3830.2025.11.004

中国医疗保险 ›› 2025, Vol. 0 ›› Issue (11) : 39-48. DOI: 10.19546/j.issn.1674-3830.2025.11.004

观察思考

中医民族医医保支付方式改革现状及影响因素分析——以新疆维吾尔自治区为例

王宁宁¹, 朱晓晨^2,3, 郑洁楠^2,3, 海沙尔江·吾守尔^2,3, 马凯丽⁴, 韩晟^2,3, 艾则孜江·艾尔肯⁵

作者信息 +

Analysis of the Current Situation and Influencing Factors of Payment Method Reform in Traditional Chinese Medicine and Ethnic Minority Medicine——A Case Study of Xinjiang Uygur Autonomous Region

Author information +

文章历史 +

摘要

目的: 调研新疆维吾尔自治区中医药与民族医药使用和支付现状,分析中医民族医医疗机构推行医保支付方式改革的影响因素,为构建符合中医民族医特色的医保支付机制提供参考依据。方法: 对10家相关单位负责人员开展半结构化访谈,对访谈内容进行描述性分析,并基于主题框架分析法开展主题编码与影响因素分析。结果: 当前新疆维吾尔自治区中医民族医医疗机构推行医保支付方式改革的影响因素涉及临床应用、支付管理、标准化问题、学科发展、政策协调等五个方面。结论: 在中医民族医医疗机构顺利推行医保支付方式改革,对中医民族医的应用发展、保护传承具有重要意义。针对其主要影响因素,建议系统构建民族医药标准化体系,夯实医保支付方式改革基础;基于现有DRG/DIP框架,构建更加符合中医民族医特色的医保支付机制;强化政策协同,探索多层次医疗保障支持体系。

Abstract

Objective: The paper attempts to investigate the current situation regarding the utilization and payment of traditional Chinese medicine (TCM) and ethnic minority medicine (EMM) in Xinjiang Uygur Autonomous Region, analyze the influencing factors for implementing medical insurance payment method reform in TCM and EMM medical institutions, and provide a reference for establishing a medical insurance payment mechanism that aligns with the characteristics of TCM and EMM. Methods: Semi-structured interviews were conducted with responsible personnel from 10 relevant institutions. Descriptive analysis was applied to the interview content, and thematic coding and influencing factor analysis were performed based on the thematic framework analysis method. Results: The current influencing factors for implementing medical insurance payment method reform in TCM and EMM medical institutions in Xinjiang Uygur Autonomous Region involve five aspects: clinical application, payment management, standardization issues, discipline development, and policy coordination. Conclusion: Promoting the successful implementation of medical insurance payment method reform in TCM and EMM medical institutions is of significant importance for the application, development, protection, and inheritance of TCM and EMM. Targeting the main influencing factors, it is recommended to systematically construct a standardized system for EMM to consolidate the foundation of the payment method reform, build a medical insurance payment mechanism more aligned with the characteristics of TCM and EMM based on the existing DRG/DIP framework, and strengthen policy coordination to explore a multi-level healthcare security support system.

导出引用

王宁宁, 朱晓晨, 郑洁楠, 海沙尔江·吾守尔, 马凯丽, 韩晟, 艾则孜江·艾尔肯. 中医民族医医保支付方式改革现状及影响因素分析——以新疆维吾尔自治区为例[J]. 中国医疗保险. 2025, 0(11): 39-48 https://doi.org/10.19546/j.issn.1674-3830.2025.11.004

Analysis of the Current Situation and Influencing Factors of Payment Method Reform in Traditional Chinese Medicine and Ethnic Minority Medicine——A Case Study of Xinjiang Uygur Autonomous Region[J]. China Health Insurance. 2025, 0(11): 39-48 https://doi.org/10.19546/j.issn.1674-3830.2025.11.004

中图分类号： F840.684 C913.7

参考文献

[1] 国务院办公厅.关于进一步深化基本医疗保险支付方式改革的指导意见:国办发〔2017〕 55号[EB/OL].(2017-06-20)[2025-09-10].https://www.gov.cn/gongbao/content/2017/content_5210497.htm.
[2] 国家医疗保障局.关于印发DRG/DIP支付方式改革三年行动计划的通知:医保发〔2021〕 48号[EB/OL].(2021-11-19)[2025-09-08].https://www.gov.cn/zhengce/zhengceku/2021-11/28/content_5653858.htm.
[3] 新疆维吾尔自治区医疗保障局.新疆医保DRG/DIP支付方式改革提前实现统筹地区全覆盖[EB/OL].(2023-12-20)[2025-09-08].https://www.xinjiang.gov.cn/xinjiang/bmdt/202312/24a89c541bc94f96adb2a4162f927773.shtml.
[4] 黄成凤,申丽君,杨燕绥.价值导向型医保付费政策效果探讨——基于柳州市中医优势病种的实证分析[J].卫生经济研究,2022,39(05):37-41.
[5] 国家医疗保障局,国家中医药管理局.关于医保支持中医药传承创新发展的指导意见:医保函〔2021〕 229号[EB/OL].(2021-12-14)[2025-09-08].https://www.gov.cn/zhengce/zhengceku/2022-01/01/content_5665996.htm.
[6] 张弘,丁科,谢俊明,等.“疗效价值付费”下的中医优势病种DRG付费方案探索[J].卫生经济研究,2021,38(12):75-76+79.
[7] 于伟,李佳宁,钟璐,等.中医优势病种按疗效价值付费改革效果分析[J].卫生经济研究,2025,42(04):23-27.
[8] 张楠,陆智华,卢展开,等.各民族医药干预痛风性关节炎临床研究进展[J].亚太传统医药,2024,20(02):55-59.
[9] 陆庆旺,周红海,田君明,等.基于数据挖掘的维吾尔医药治疗骨伤科用药规律研究分析[J].中草药,2021,52(19):5996-6004.
[10] WANG Y, ZHANG J, DING Y,et al.Prevalence of hypertension among adults in remote rural areas of Xinjiang, China[J]. International journal of environmental research and public health,2016,13(6):524.
[11] 王惠琳,帕丽达·阿布利孜,李永平,等.新疆地区高原环境下皮肤病发病情况及相关危险因素调查[J].实用皮肤病学杂志,2025,18(01):16-20+80.
[12] 斯拉甫·艾白,玉苏甫·买提努尔,吐尔洪·艾买尔,等.维吾尔医优势病种规范化诊治关键技术的研究与应用[J].中国民族医药杂志,2016,22(06):28-32.
[13] 陈诺. 新疆维吾尔族生物多样性相关传统知识研究[D].北京:中央民族大学,2021.
[14] 贾艳菊,王孟,崔洪艳,等.评估医疗机构救治严重产后出血能力的质性访谈[J].国际妇产科学杂志,2024,51(3):329-335.
[15] ELTAYBANI S, ABDELWARETH M, ABOU-ZEID NA, et al.Recommendations to prevent nursing errors: content analysis of semi-structured interviews with intensive care unit nurses in a developing country[J]. Journal of nursing management, 2020,28(3):690-698.
[16] 盖彤,祁鹏,范姗姗,等.基于主题框架分析方法的商业医疗保险发展阻碍模型构建[J].中国医疗保险,2024(1):43-49.
[17] 天山网.支持中医药传承创新发展新疆130家中医医疗机构纳入医保定点[EB/OL].(2024-02-06)[2025-11-05].https://www.ts.cn/xwzx/shxw/202402/t20240206_19068294.shtml.
[18] 陈笛,苏菁涵,吕香伟,等.DIP支付方式下低倍率病例特征及医院管理策略探索[J].中国卫生经济,2025,44(08):45-48.
[19] 国务院办公厅.关于加强三级公立医院绩效考核工作的意见:国办发〔2019〕 4号[EB/OL].(2019-01-30)[2025-09-08].http://www.gov.cn/zhengce/content/2019-01/30/content_5362266.htm.
[20] 国家中医药管理局办公室.对十三届全国人大五次会议第4290号建议的答复[EB/OL].(2023-01-19)[2025-09-08].http://www.natcm.gov.cn/bangongshi/gongzuodongtai/2023-01-19/28986.html.
[21] 周钢,单莲莲,王亚丽,等.新疆民族药质量标准研究现状及展望[J].中国药事,2024,38(1):28-34.
[22] 吴明,王雨晨,霍茹,等.二级公立少数民族医医院绩效考核指标体系适宜性研究[J].中医药导报,2025,31(5):85-88+117.
[23] 赵俊娟,李菲.普惠型商业医疗保险参保意愿影响因素分析[J].中国卫生事业管理,2024,41(5):523-528.