目的：

在卫生费用持续增长的国内外态势下，提质增效已经成为绝大多数公立医院管理者的共识。本研究拟通过对北京某三级公立医院（A医院）进行实证分析，分析真实世界费用结构和费用增长趋势，以及影响因素，深度挖掘医院优化医保费用结构及提质增效的经验与启示，为现代化医院医保的管理谏言和献策。

方法：

本文采用定量与定性相结合的研究方法，资料搜集方法包括文献法，问卷法和访谈法。定量分析的部分数据来自于某三级公立医院的真实世界数据，数据源来自北京市医疗保险信息系统中2014-2019年北京市城镇职工基本医疗保险患者在A医院发生的所有费用数据。数据分析方法包括描述性统计分析、结构变动度分析、T检验和χ²检验方法。

结果：

控费机制方面，A医院多措并举，取得显著成效；建立了以院领导为中心的专项管理课题和MDT管理团队；建立分析预警及反馈机制；探究新型管理方式做好药品、耗材和特殊病管理；构建绩效评价专项考核机制；借助信息技术支持，开发管理模块；加强宣教力度，强化全院人员医保控费意识等；数据分析方面获得印证：A医院2019年与2018年相比，医保基金总体增速放缓，门诊医保基金增速为-1%，使用效率提高；费用结构方面：A医院总费用结构变动度为5.76%，其中药品、材料、其他费用呈负向变动，检查化验费与手术费用呈正向变动；门急诊费用结构变动度为8.72%，其中药品呈负向变动，达5.18%； 药品费用对结构改变的贡献度最高，达59.40%，说明门诊药品贡献最大；住院费用结构变动度为13.67%；手术治疗费、材料费、药费对结构变动贡献率分别为49.96%、26.99%和10.53%，说明手术治疗费结构占比贡献显著，符合预期。问卷调查方面，883名在职人员随机线上参与；控费认知情况护士好于医生；总体认可度超过半数；但61%认为存在不合理的地方；30%的医生对控费措施的合理性存疑；60%认为会影响诊疗行为；80.5%的医师赞同科室配置经营助理；78%的医师认为加快信息化建设至关重要；深度访谈方面也发现，医院医保控费举措仍存在落实与执行困难的现状。

结论：

A医院医保费用结构变动效果显著，医保基金总额预付从超支变为微结余；医保控费颇具成效，多种费用和结构指标都得到了明显优化；但是，需要重视医务人员对医保控费措施的认知问题，尤其加强医生的宣传培训工作。笔者认为，要做好医保费用结构调整及控费工作，需要发挥临床人员主体责任；与国家、医院、医保一起共同发力，相向而行，才能实现医院医保的高质量发展。

Objectives: 

With the continuous increase of health costs from both domestic and overseas, improving quality and efficiency has become the consensus of most public hospital administrators. This study intends to conduct an empirical analysis on a tertiary public hospital in Beijing（Hospital A） to analyze the real cost structure and growth trend, as well as the effect factors. The experience and enlightenment of optimizing medical insurance cost structure and improving quality and efficiency are deeply explored to offer suggestions for the management of modern hospital medical insurance. 

Methods: 

This paper adopts the combination of quantitative and qualitative research methods. Data were collected by literature, questionnaire and interviews. Part of the data for quantitative analysis came from factual data of a tertiary public hospital, and the data source came from the data of all the expenses of patients with Beijing urban employees’ basic medical insurance in Hospital A from 2014 to 2019 in the Beijing Medical insurance Information System. Data were analyzed through abundant analysis methods include descriptive statistical analysis, structural variation analysis, T test and χ2 test. 

Results: 

In terms of cost control mechanism, Hospital A adopted multiple measures and achieved remarkable results, which include established a special management project and MDT management team centered on hospital leaders, built on analysis warning and feedback mechanism, explored new management methods to manage drugs, consumables and special diseases, constructed a special performance evaluation mechanism, exploited management module with information technology support and strengthen propaganda and education to improve the awareness of medical insurance cost control. Data analysis was verified: Compared with 2018, the overall growth rate of medical insurance fund in Hospital A slowed down in 2019, the growth rate of outpatient medical insurance fund was -1%, and the utilization efficiency improved. In the matter of cost structure, the variation degree of the total cost structure of hospital A was 5.76%, in which the cost of drugs, materials and other expenses changed negatively, and the cost of examination and laboratory test changed positively with the cost of surgery. The change degree of outpatient and emergency cost structure was 8.72%, in which the change degree of drug cost structure was negative, and the absolute change of drug cost structure was 5.18%, indicating a significant change. The contribution of drug cost to structural change was the highest, up to 59.40%, indicating that outpatient drugs contributed the most. The variation of hospitalization cost structure was 13.67%. The contribution rates of surgical treatment cost, material cost and medicine cost to structural changes were 49.96%, 26.99% and 10.53% respectively, indicating that the structural contribution of surgical treatment cost was significant and in line with expectations. In the questionnaire survey, 883 in-service personnel participated randomly online. Nurses are better than doctors in cognition of cost control. The overall approval rate is more than half, but 61% think there is something unreasonable. 30% of doctors doubt the reasonableness of fee control measures. 60% thought it would affect treatment behaviors. 80.5% of physicians agreed to configure management assistant in the department. 78% of doctors think it is very important to speed up information construction. It is also found that the implementation and enforcement of hospital medical insurance cost control measures are still difficult in depth interviews.

Conclusions:

The effect of hospital A's medical insurance cost structure alteration is significant, and the total prepayment of medical insurance fund changes from overspend to slight balance. The cost control of medical insurance has been effective. A variety of cost and structure indicators have been significantly optimized. However, it is necessary to pay attention to medical staff's cognition of medical insurance cost control measures, especially to strengthen the propagandization and training of doctors. To sum up, the author believes that in order to adjust the structure of medical insurance cost and achieve further control, clinical staff play an important role as principal part. Only if the state, the hospital and the medical insurance have made concerted efforts to move towards the same goal, can we realize the high-quality development of hospital medical insurance.