摘要
目的: 在DRG/DIP按病种付费改革深化的背景下,分析河北省特例单议线上“双盲”评审的运行成效与申报结构,提出规范化治理路径。方法: 采用政策文本分析与描述性统计,以河北省2024—2025年度特例单议业务数据为研究对象,按“制度规则—程序运行—结果表现—治理改进”框架,计算申报机构数、申报量、通过率及不同申报条件构成。结果: 2024年申报47070例,通过28548例,通过率60.65%;2025年申报90130例,通过61975例,通过率68.78%,同比提高8.13个百分点。疑难复杂及多学科联合诊疗类占申报量49.53%,新药新技术类通过率最高（81.76%）。结论: 河北线上“双盲”评审在扩大制度覆盖、保障复杂危重病例方面成效积极。应进一步在分层证据标准、量表化裁量、专家校准、反向审计、结构化理由说明和全过程留痕等方面推进规范化,并完善机构、病种和地区层面的精细化监测。
Abstract
Objective: The paper analyzes the operational effectiveness and application structure of Hebei Province's online "double-blind" review for special-case individual review in the context of deepening DRG/DIP case-based payment, and proposes a standardized governance pathway. Methods: Policy text analysis and descriptive statistics were employed. Using Hebei Province's 2024-2025 special case review data and following an "institutional rules-procedural operation-outcome performance-governance improvement" framework, the study calculated the number of application institutions, application cases, approval rates, and the composition of different application conditions. Results: In 2024, 47070 applications were submitted with 28548 approved (approval rate 60.65%); in 2025, 90130 applications were submitted with 61975 approved (approval rate 68.78%), representing an increase of 8.13 percentage points. Complex cases requiring multidisciplinary care accounted for 49.53% of all applications, while new drug and technology cases achieved the highest approval rate (81.76%). Conclusions: Hebei Province's online "double-blind" review has demonstrated positive effectiveness in expanding institutional coverage and ensuring coverage of complex and critical cases. Further standardization should focus on stratified evidence standards, scaled adjudication, expert calibration, reverse auditing, structured rationale statements, and full-process traceability, while refining monitoring at the institutional, disease, and regional levels.
关键词
特例单议 /
双盲评审 /
按病种付费 /
程序正当 /
医保支付
Key words
special-case individual review /
double-blind review /
case-based payment /
procedural due process /
medical insurance payment
魏宁, 彭啟飞, 东野厚娜, 刘焕龙, 李秋童.
特例单议从“例外补偿”到“程序正当”的规范化路径——基于河北省线上“双盲”评审的实证分析[J]. 中国医疗保险. 2026, 0(8): 65-70 https://doi.org/10.19546/j.issn.1674-3830.2026.8.008
The Standardization Pathway of Special Case Review from "Exceptional Compensation" to "Procedural Justice"—— An Empirical Analysis Based on Online "Double-Blind" Review in Hebei Province[J]. China Health Insurance. 2026, 0(8): 65-70 https://doi.org/10.19546/j.issn.1674-3830.2026.8.008
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基金
河北省医学科学研究课题“髋膝关节置换快速康复住院路径构建与DIP评价研究”（20270352）
