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หลักเกณฑ์การดำเนินงานและการบริหารจัดการ กองทุนหลักประกันสุขภาพแห่งชาติ

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หลักเกณฑ์การดำเนินงานและการบริหารจัดการ กองทุนหลักประกันสุขภาพแห่งชาติ ปีงบประมาณ 2557. กรกฎาคม 2556 สำนักงานหลักประกันสุขภาพ แห่งชาติ. ประเด็นนำเสนอ. งบ กองทุนหลักประกันสุขภาพ แห่งชาติปีงบประมาณ 2557 ที่ได้รับ กรอบ ในการกำหนดแนวทางการ บริหารกองทุน หลักประกันสุขภาพ แห่งชาติปีงบประมาณ 2557 - PowerPoint PPT Presentation

Text of หลักเกณฑ์การดำเนินงานและการบริหารจัดการ...

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2557 25561 2557 2557 25572 2557 347 ..2556 2557 ( .)25 ..2556. 2556 ( .39 2)28 ..2556 11 ..255612 ..2556 26 ..2556 14 ..2556.. . 25 ..2556 2557 25 ..2556

. 2556 () ( .39 2)25 ..2556 25 ..255626 ..2556 26 ..2556 2557 ( .39 2)23 ..2556 2557 ()30 ..2556 2557 ()5 2557-

6 2557- 2556[] 2557 [] 2557 []57 > 56%1. 983.49 1,083.17 1,056.96 73.47 7% 2. 975.85 1,051.17 1,018.35 42.50 4%3. 60.99 (60.99)-100%4. 262.10281.02281.02 18.927%5. l313.70 383.61383.6169.9122%6. 12.88 14.95 14.95 2.07 16%7. 7.20 9.26 8.19 0.99 14%8. 128.69 128.69 128.69 - 0%9. 4.76 - - (4.76)-100%10. (.41)5.19 3.32 3.32 (1.87)-36%11. 0.75 0.54 - (0.75)-100% 1-112,755.60 2,955.91 2,895.09 139.49 5.1%

() 2557 1. 7 2557 [] 2557 []1. 1,056.96 1,056.96 2. 1,018.35 1,027.94 3. 281.02271.33 4. 383.61 383.61 5. 14.95 14.95 6. 8.19 8.19 7. 128.69 128.69 8. (. 41) 3.32 3.32 9. - 0.102,895.09 2,895.09

2557 15,000 300 ( 2556)

8 25579 2557 (1) -> ... ..2545 18(1), 18(4), 18(13) , 38, 41, 46, 47

Health Need

1011 ... .. () () () ()12 () ()13 (1)... .. 2545.18(1) .18(4) .18(13) .38 .41 41.46(1) . 50(4) DRG ( / / ) ().46(2) () (2)... .. 2545.46(3) ( / / ) ( ).46(4) ( hardship, ) ( diff cap ) ( / / ) ( )HIV ARV , .47 () () 255716 UHC1. 1.1 .46 (1), (2) , (3), (4)1) Health need2) 1.2 .46 (1)2)4) 1.3 .46 (1), (2) , (3), (4)1) Health need2) 1.4 .46 (2) , (3), (4) .471) Health need2) 3) 4) 1.5 .46 (2) , (4) .473) 1.6 .46 (2) , (3) .472) 1.7 .46 (3) 2) 1.8 (.41).41 1.9 .18 (4)2. .46 (4) .471) Health need2) 3. .46 (2) , (3), (4) 2) 3) 4. /.46 (4)1) Health need2) 5. ().46 (2), (4)2) 4) 6. ().46 (2)

2) 255717 2557 6 ( 2nd prevention /) () ()

18191920 2557 2557 [] 2557 []1. 1,056.96 1,056.96 2. 1,018.35 1,027.94 3. 281.02271.33 4. 383.61 383.61 5. 14.95 14.95 6. 8.19 8.19 7. 128.69 128.69 8. (.41) 3.32 3.32 9. - 0.102,895.09 2,895.09

1.1 211.1 OP- 2557 22 1,056.96 3

2556 2557(1) (928.40)(1) (1,001.87)(2) (18.09)(2) (18.09)(3) (37)(3) (37) (1) (2) .13 . 221.1 OP- 2557(1) (1.1) 1,001.87 2

23 2556 25571.1) 757.39 (diff. capitation) .. 10% CUP CUP 10% 1.1) 830.86 (diff. capitation) 10% 1.2) 171.01 1.2) 171.01 231.1 OP- 2557 (1) ()(1.2) .13 . (1.3) .. ( Hardship)(1.4) . OP

24241.1 OP- 2557(2) 2556 (2.1) 18.09 2 ( 2556) 17.28 OP/PP individual records 0.81 (2.2) . 13 .

25251.1 OP- 25573) () 37 (District Health System) - (Social enterprise) 2557 2 26 2556 25571) (30)1) (32)2) (7)2) (5)26 1) (32 ) Quality and Outcome Framework (QOF) 4 global budget UC P&P P&P . (CUP) . CUP ( DHS: District health system) 27() ()(Quality and Outcome Framework :QOF) 257728 1: 1.1 1 2 2: 2.1 OP /. ( PCU)2.2 (PCU)2.3 . ( PCU)2.4 . HT ( PCU) 3: 3.1 ( PCU)3.2 (CUP) 4:

QOF : Smart health .28 (QOF) 29 1: 2: 3: 4: QOF- - (CBR)- 2557-2559 2557-2559 2558-2559 P&P P&P 2) (5 ) .. 2007 (six building blocks primary health care system strengthening ) 1 4 UC

30 .. 2007 (six building blocks primary health care system strengthening ) (District Health System :DHS) ( 38 2) . (PCA) . ./. () P&P

1.2 321.2 IP- 2557 (1) 2556 2557 0.10 ( 2557) 9.69 1,027.94

33 = 1,018.35-0.10+9.69=1,027.94 331.2 IP- 2557 (2) global budget (GB) 2.1) () 7 ( 7 ) (Adjusted relative weight : adjRW) 25572.2) GB 55% workload 45% ( 2556)2.3) 34342. IP- 2557 (3)3.1) 20 . . DRGs version 5 3.2) DRGs global budget

2556 / DRG .

35351.2 IP- 2557 (4) 5.1) . adjRW .5.2) global budget 30 2557 ( GB 2557) (sum adjRW) 2557 10 (.56-.57) 12 GB .. 2557 12 (1) 2557 GB (1) (2) GB . 2557 Global budget 2557 Global budget

36361.3 (/ / )371.3 2557 (1)381. (HC)2. (AE,PUC)1.1 1) OP-AE 1) Thalassemia 2) OP-refer 2) Hemophilia 3) 3) STEMI (ST evaluated MI) 4) 4) Stroke 5) 5) Methadone maintenance therapy 6) OI [Crpyto/CMV]-OP/IP3. 7) .2 1) Asthma & COPD1.2 2) Tuberculosis 1) Instrument-OP&IP 3) Leukemia & Lymphoma [] 2) Chemo/Radia-OP 4) Cataract [all] 3) Dialysis acute case-OP/IP 5) Laser project for diabetic retinopathy 5) NONI 6) () 6) 7) (Morphine ) 8) - ( 18 ) - - - cornel transplant 381.3 2557 (2) 2556 (9.69)

391.4 40(1) NPP & Central procurement (23 ./)(3) P&P Basic Services(192 ./)(2) P&P Area Health Services(66.38 ./) (4) (7.50 ./)

/.,/ P&P Capitation( 288.88 x . 64.871 ) 383.61 /.UC 48.852 P&P Dental(10 ./) 2557 .13 (2) (3) P&P . P&P P&P(45.00 ./)/(21.38 ./+)Capitation+workload (162 ./)Quality Performance(20 ./) P&P 2557 (1) 2556 (P&P) 288.88 () 4 P&P (NPP & Central procurement )P&P (P&P area health services)P&P (P&P basic services) P&P : 255625571. NPP & Central procurement 25.72232. PP Area health services 2.1 4045 2.2 PPA +17.421.383. PP basic services 3.1 General activity ( 2557 )99.96172 3.2 Quality performance25204. 7.687.55. ()16.6 3232.36288.88 P&P 2557 (2) .13 (2) (3) P&P . P&P P&P

P&P 2557 (1) P&P 23

(1.1) Central Procurement (19.15 )

EPI & ( 2 4 6 2 ) (1.2) National priority Programs (3.85 )/ P&P 2557 (2) P&P 66.38

(2.1) (45 ) 40 5 (2.2) (21.38 ) / / global budget . 45 P&P 2557 (3) P&P 192

(3.1) (162 ) (.) . ()(3.2) (10 ) (.) . (3.3) (20 ) 46 P&P 2557 (4) P&P) 7.50 ( / )/ 6 global budget . .47 P&P P&P 2557 20 (8 Flagships) P&P P&P P&P 48

1.5 49 ( 1.50 ) ( 13.45 ) (14.95 ) / . ( ) sub acute( OPD )

50 2557255650 2557 (1)51

10% 2556 . 700 36 / 3 (PT . 90% OT ././ . 30%) 1 ./ 12

51 255752 (KPI)255625571.80%90%2. O&M 60%60%3. 24 ( 2 .)36 ( 3 .)4. 3 /521.6 53 ( 0.57 ) ( 7.62 ) (8.19 ) 1.6 2557 1 / / 4 4 2 (2557-2558) .. 225 1.8 Global budget / . 13 . . 8.19 /. : 1 = 6.79 (82.9%) 2 = 1.4 (17.1%)

1 = 225 X 180,000 = 40,500,000 2 2 . . 2 . x 13 = 26 . =28 . 2 = 68.5 .54 certify CUP .. 5 1.6 255755 255756 25571. certify ( 55 = 331 )590

2. ( 55 = 3,607,259 ) 20

3. .. 5 ( 55= 44.66%) 70

4. 16

1.7 57581.7 2557 (128.69 ) OP(55.10 ) IP(53.59 ) PP(20 ) 20 // OP-PP-IP IP (sum adjRW) 80 1.8 (.41)1.9 0.10 2557 ( 2556) 2556 59591.10 60 2557 () .. 60% UHOSNET 8 17.52% 24.58% OP-, IP-, P&P61255625572557-/56/571. 31,408.150733,292.638736,822.70805,414.55733,530.0693 2. . ()163.8476173.6785173.46679.6191-0.2118 3. 1,223.28571,296.68281,385.1163161.8306 88.4335 32,795.284034,763.0000 38,381.2910 5,586.00703,618.2910 : 2557 (1) 2556 2 .. OP-IP-P&P . ( ..) 3.1 13-. . 3.2 % OP, P&P IP ..

62 .. 2557(1)

.. UC (unit cost) (efficient and (performance) .. .. 2557 (2) .. 4.1 (CUP) 3 CUP .. 4.2 ( CF) CF 4.3 (unit cost) (average cost) (efficient and (performance) ..

64 64 .. 2557 (3)4.4 CUP CUP hardship CUP CF CUP LOI (letter of intent) (Rehabilitation financial plan) CF CUP ..

65 652. 662. 2557 2556 (Plasma Viral Load) .. 2553 1 6

67HIV/AIDS 2,946.997 (2,874.497 ) (72.5 ) 188,000 167,100 20,900 3. 683. 2557 2556 2556 [] 2557 [] () ()1. 31,523 4,097,975,000 35,429 5,154,104,000 - CAPD16,513 19,195 - HD 9,324 9,848 - HD Self-Pay4,522 5,213 - KT 156 144 - KT 1,008 1,0292. 22,810,000 24,700,000 31,5234,120,785,000 35,4295,178,804,000 1 2 4. ( 2nd prevention /)70 2nd prevention(748 .) (53.240 .) : 2nd prevention = 60:40 NCD 2.1) 90% 2.2) 10% 2nd prevention M&E4. DM/HT 2557 DM/HT(801.240 .)5. ()72 () 2557 ( Hardship) .. () .. Hardship

736. ()74 () 2557 2 1.1) 2,000 1.2) 1,000 2 1.1) 1.2) . 2)

75

76

KPI _PP 2557 . ERROR:#REF!8 FS1 5ERROR:#REF!8 FS2 25 ERROR:#REF!8FS/BS3 12 60ERROR:#REF!BS7 5 90ERROR:#REF!BS8 100ERROR:#REF!BS9 3 65 0-2 ERROR:#REF!BS10 6 50ERROR:#REF!BS12 0-2 90 ERROR:#REF!BS12 1 BCG 90ERROR:#REF!BS12 1 DTP-HB3 90ERROR:#REF!BS12 1 OPV3 90ERROR:#REF!BS12 2 DTP4 90ERROR:#REF!BS12 2 OPV4 90ERROR:#REF!BS12 2 JE2 90ERROR:#REF!8FS/BS12 1 MMR 958FS 0.5 ERROR:#REF!8FS/BS13 0-2 70ERROR:#REF!BS14 0-2 80 3-5 ERROR:#REF!8 FS15 0-5 ERROR:#REF!ERROR:#REF!8 FS16 ( 3-3 11 ) 57ERROR:#REF!BS17 3-5 90ERROR:#REF!BS17.1 3 JE3 90ERROR:#REF!BS17.2 5 DTP5 90ERROR:#REF!BS17.3 5 OPV5 90ERROR:#REF!8FS/BS18 3-5 70ERROR:#REF!BS19 3-5 80ERROR:#REF!BS20 3 70ERROR:#REF!BS20 3 70ERROR:#REF!BS20 3 Fluorine vanish 50 6-12 ERROR:#REF!8 FS21 6-12 70ERROR:#REF!22 50ERROR:#REF!8FS/BS23.1MMR .1 95ERROR:#REF!8FS/BS23.2 dT .6 95ERROR:#REF!8FS/BS24.1 1 85ERROR:#REF!8FS/BS24.2 1 30ERROR:#REF!8FS/BS26 30-60 80ERROR:#REF!8FS/BS27 30-60 2557 80ERROR:#REF!8 FS28.1 30-60 1 2 70ERROR:#REF!8 FS28.2 30-60 1 2 7029.1 15-34 9029.1