缺血性心脏病DRG与DIP付费模式对比分析  

Comparative Analysis of DRG and DIP Payment Management Models for Ischemic Heart Disease

作　　者：蒋文博 刘莉[2] 梁浩晖[2] 廖钧 Jiang Wenbo;Liu Li;Liang Haohui;Liao Jun(Shenzhen Second People’s Hospital,Shenzhen,518035)

机构地区：[1]深圳市第二人民医院物价医保部,深圳518035 [2]深圳市第二人民医院,深圳518035

出　　处：《中国医疗保险》2022年第2期70-73,共4页China Health Insurance

摘　　要：目的:以按项目付费作为参考标准,比较缺血性心脏病入组DRG和入组DIP的医保支付费用差异及与按项目付费费用之间的差异,探讨缺血性心脏病用DRG和DIP支付方式的优缺点。方法:根据治疗方式不同,把1296例缺血性心脏病病例分为无手术组(617)、检查组(276)和手术组(403)。采用R、Office Excel等工具分析各组的费用结构和它们之间的费用差异,比较各组对应的DRG和DIP平均支付费用及与按项目付费费用的差异,以此探讨基于DRG和DIP制度下缺血性心脏病的现行最佳医保支付途径。结果:(1)不同治疗方式的缺血性心脏病之间的费用差异显著,手术组的医疗费用明显高于检查组的医疗费用,检查组的医疗费用明显高于无手术组的医疗费用。(2)通过大数据得出,DRG付费的测算费用与操作较少、成本较少病例的实际费用相似度更高;DIP病种分值付费的测算费用与操作较多,病情严重病例的实际费用相似度更高。结论:DRG付费能覆盖大多数缺血性心脏病的费用成本,但无法覆盖成本较高病例的费用成本,且支付费用与按项目付费的费用差异性大;DIP病种分值付费较DRG付费更接近病情严重、操作复杂的缺血性心脏病疾病病例的实际费用,但无法准确反映成本较少病例的实际费用;DRG和DIP都能对医院成本管控和减少患者负担起到积极作用,但从精细化管理的角度上看DIP优于DRG。无法覆盖的病例,应加强成本管控,并继续探讨DRG/DIP分组细化规则。Objective:Based on the standard of payment by medical item,the differences between DRG and DIP in medicare reimbursement and the standard of payment by medical item were compared to explore the advantages and disadvantages of DRG and DIP reimbursement for ischemic heart disease.Methods:According to the different treatment methods,1296 patients with ischemic heart disease were divided into non operation group(617),examination group(276)and operation group(403).R,Office Excel and other tools were used to analyze the cost structure of each group and the cost differences among them,and to compare the corresponding DRG and DIP average reimbursement,so as to explore the best current medicare reimbursement approach for ischemic heart disease under DRG and DIP system.Results:(1)There was a significant difference in the cost of ischemic heart disease with different treatment methods.The medical cost of the operation group was significantly higher than that of the examination group,and the medical cost of the examination group was significantly higher than that of the non-operation group.(2)The estimated cost of DRG payments was more similar to the actual cost of cases with fewer operations and fewer costs.The measured cost of the DIP disease score payment was more similar to the actual cost of more intensive and severe cases.Conclusion:DRG payment can cover the cost of ischemic hearts diseases in most cases,but does not cover the cost of high-cost cases and there is a large difference between DRG payment and payment by medical item.Compared with DRG payment,the DIP payment is closer to the actual cost of severe and complex ischemic heart disease cases,but cannot accurately reflect the actual cost of less costly cases.Both DRG and DIP can play a positive role in hospital cost control and reducing patient burden,but DIP is superior to DRG from the perspective of fine management.For cases that cannot be covered,cost control should be strengthened and DRG and DIP grouping refinement rules continue to be discussed.

关 键 词：缺血性心脏病 DRG 费用结构 DIP 

分 类 号：F840.684[经济管理—保险] C913.7[社会学]