哈尔滨市医保结算中DRG分组测算的问题分析  

Analysis and Discussion on DRG Grouping of Medical Insurance Settlement Records in Harbin

作　　者：李会玲[1] 曹蕊[1] 许凤娟[1] 蔡秀芝 王大鹏[3] LI Hui-ling;CAO Rui;XU Feng-juan(The First Hospital of Harbin Medical University,Harbin,150001,China)

机构地区：[1]哈尔滨医科大学附属第一医院,哈尔滨150001 [2]哈尔滨市疾控中心,哈尔滨150001 [3]哈尔滨医科大学附属肿瘤医院,哈尔滨150001

出　　处：《中国卫生经济》2021年第8期37-40,共4页Chinese Health Economics

摘　　要：目的:运用DRG分组器分析哈尔滨市DRG试点医院医保结算病案,根据分组结果发现问题、分析原因,并提出相应的改进措施。方法:选取样本医院出院时间为2018年12月1日—2020年3月31日,与市医保结算相关病案,从病案首页及结算数据中获取相关信息进行分组测算,运用数据统计归纳总结测试结果。结果:通过分组测算,发现未入组病案存在编码缺失、分组器设置缺陷,已入组病案存在编码及费用偏离问题。结论:推进DRG付费模式的顺利实施,需要完善医疗机构信息化建设,落实病案管理制度及诊疗规范,转变医疗机构运营管理模式,完善DRG分组器。Objective:According to the grouping results,medical records of medical insurance settlement in Diagnosis Related Group(DRG) pilot hospitals of Harbin by DRG grouping device were explored to find out the problems,analyze the reasons,and advance the improved measure.Methods:It used the medical insurance settlement information of medical records of medical insurance settlement from December 2018 to March 2020 in Harbin pilot hospitals,and calculated the relevant information from the first page of medical records and settlement data,and used mathematical statistics to summarize the test results.Results:Through grouping calculation,it was found that there were missing codes and defects of grouping device in non-enrolled medical records.There were problems of coding and cost deviation in enrolled medical records.Conclusion:In order to promote the successful implementation of DRG payment mode,it needed to improve the information construction of hospitals,implement the medical record management system and standardized treatment,and change the operation and management mode of the hospitals,and improve the DRG grouping device.

关 键 词：按疾病诊断相关分组 医保结算 病案 哈尔滨 

分 类 号：R1-9[医药卫生—公共卫生与预防医学] F840.613[经济管理—保险]