关键词: 结核,肺, 保险,健康,补偿, 临床路径, 患病代价, 策略

Abstract:

Objective To evaluate the effect of disease based full-course payment in Dehui City, a pilot area for the payment reform of National Health Commission of China-Bill and Melinda Gates Foundation TB Collaboration Project Phase Ⅲ in Jilin Province, and provide reference for tuberculosis (TB) prevention and control strategies during the 14th Five-Year Plan. Methods In 2018, under the guidance of national experts, a localized clinical pathway was formulated. The payment standard was determined according to this clinical pathway and actual costs (3600 yuan for outpatient and 9000 yuan for full course treatment). Outpatient expenses were packaged and paid per person for the full treatment course, while hospitalization expenses were paid in accordance with disease based payment. Reimbursement threshold for outpatients and inpatients was cancelled and medical expenses were reimbursed at a proportion of 70%. Data was collected and analyzed for costs of diagnosis and treatment of outpatient and inpatient pulmonary tuberculosis (PTB) patients in Dehui City before and after pilot project implementation during 2017 and 2018. Results The proportion of hospitalization for PTB patients decreased from 16.9% (87/515) in 2017 to 14.5% (100/689) in 2018. In 2018, outpatient expenses decreased by 18.1% (167706.8/928481.2) year-on-year, and hospitalization expenses decreased by 6.6% (29318.4/445946.6) year-on-year. The average expense of outpatient per visit and the average expense of inpatient per visit were 340.2 yuan and 4044.9 yuan in 2018, which had decreased by 29.5% (142.6/482.8) and 21.1% (1080.9/5125.8) compared with 2017, respectively. The median expense per PTB patient (not including pleurisy TB) who completed the full treatment course in 2018 was 3651.3 (1952.5, 6122.9) yuan, which decreased by 20.5% (941.3/4592.6) compared with 2017. In 2018, the outpatient and inpatient out-of-pocket proportions were both 30.0% (228232.3/760774.4; 124988.5/416628.2), which were lower than those in 2017 (outpatient 38.5% (357674.5/928481.2) and inpatient 33.2% (147865.9/445946.6)). The difference was statistically significant (χ²=1016.000, P<0.001; χ²=186.000, P<0.001). Conclusion The disease based payment model for full treatment course in Dehui City adopted intervention measures including standardized mechanism, patient service packages, which limited the unreasonable growth of medical expenses and reduced the patients’ economic burden.

Key words: Tuberculosis,pulmonary, Insurance,health,reimbursement, Critical pathways, Cost of illness, Strategy