医保DRG付费改革下某三甲医院分级诊疗下沉病组路径初探与思考  

Exploration and thinking on the path of hierarchical diagnosis and treatment of sinking disease groups in a city’s Grade Ⅲ hospital under the DRG payment reform of medical insurance

作　　者：贾晓倩 王珩[1,2] 蒋心梅[2] 赵允伍 王晓松 JIA Xiaoqian;WANG Heng;JIANG Xinmei;ZHAO Yunwu;WANG Xiaosong(School of Health Service Management,Anhui Medical University,Hefei,Anhui Province,230032,PRC)

机构地区：[1]安徽医科大学卫生管理学院,安徽省合肥市230032 [2]安徽医科大学第一附属医院,安徽省合肥市230022

出　　处：《中国医院》2022年第9期6-9,共4页Chinese Hospitals

基　　金：国家重点研发计划(2020YFC2006500,2020YFC2006502);2021年度安徽高校人文社会科学研究重点项目“现行医保政策下医院管理创新研究”(SK2021A0170)。

摘　　要：目的:通过对某三甲医院医保DRG付费下的现行病种进行分析,初步探索基础病常见病病组下沉路径,助推区域分级诊疗的建设,以更好适应医保支付方式改革时代的全面到来。方法:通过对DRG病组分组权重RW值聚类分析,确定医院病种的基本区间,结合病组超支结余情况、平均住院时间变异系数、平均医疗费用变异系数、标化时间消耗指数、标化费用消耗指数、标化西药费用消耗指数、标化中成药费用消耗指数、标化材料费用消耗指数、标化检查费用消耗指数、有无主手术、合并症并发症情况、人均自付比、参保人来源地等指标探索医院病种下沉路径,并进行实证分析。结果:初步探索结果基本吻合医院现行病种发展情况,医院整体收治病例以0.5≤RW<2为主,RW<0.5和RW≥2病组较少;建议针对低权重高费用高指标病种进行合理下沉或转为日间诊疗,适当收治中低权重低费用低指标病种,重点发展高权重低费用低指标病种,着力改善高权重高费用高指标病种或进行适当地上转。结论:未来病组下沉路径有待进一步修改完善,医院收治病组结构应逐步优化,同时注重专科、门诊诊疗和强基层建设等,三级医院对疑难杂症医疗定位有待进一步落实,进一步推进DRG付费改革下分级诊疗工作的发展与突破。Objective:Through the analysis of the current diseases under the medical insurance DRG payment of a Grade Ⅲ hospital in a city,to preliminarily explore the sinking standard of common disease groups of basic diseases,and promote the construction of regional hierarchical diagnosis and treatment,so as to better adapt to the era of embracing the reform of medical insurance payment mode.Methods:Through the cluster analysis of the grouping weight RW value of DRG disease groups,the basic interval of hospital diseases was determined.Combined with the overspending balance of the disease groups,the variation coefficient of average hospital stay,the variation coefficient of average medical expenses,the standardized time consumption index,the standardized cost consumption index,the standardized western medicine cost consumption index,the standardized Chinese patent medicine cost consumption index,the standardized material cost consumption index,the standardized examination cost consumption index,whether there are major operations,complications and comorbidity,per capita out of pocket ratio,the place of origin of the insured and other indicators to explore the sinking path of hospital diseases,and conduct empirical analysis.Results:The preliminary exploration results are consistent with the current development of diseases in the hospital.The overall cases treated in the hospital are mainly 0.5 ≤ RW < 2,and there are fewer RW<0.5 and RW ≥2 disease groups.It is suggested that the low weight,high-cost and high index diseases should be reasonably sunk or transferred to daytime diagnosis and treatment,the low weight,low-cost and low index diseases should be appropriately admitted,the high weight,low-cost and low index diseases should be developed,and efforts should be made to improve the high weight,high-cost and high index diseases or carry out the appropriate upward transfer.Conclusion:In the future,the sinking standard of disease groups needs to be further modified and improved.The structure of the hospital admission grou

关 键 词：医保支付 支付方式 分级诊疗 病组下沉 下沉路径 

分 类 号：R197.3[医药卫生—卫生事业管理]