CHS-DRG分组方案在我国医保支付应用中的局限性与启示  

Limitations and enlightenment of CHS-DRG classification scheme in the application of medical insurance payment in China

作　　者：高静[1] 涂开荣 贠淑芳 王丽[1] 张翠红[1] GAO Jing;TU Kairong;YUN Shufang;WANG Li;ZHANG Cuihong(Xinjiang Sixth Hospital affiliated to Xinjiang Medical University,Urumqi Xinjiang 830092,China)

机构地区：[1]新疆医科大学第六附属医院,新疆乌鲁木齐830092

出　　处：《卫生软科学》2023年第3期6-10,17,共6页Soft Science of Health

基　　金：国家自然科学基金资助项目-基于非物质激励的医务人员绩效管理工具研发与应用研究(81660231)。

摘　　要：[目的]分析新诊疗技术与不同范围手术病例在《国家医疗保障疾病诊断相关分组与付费技术规范》分组结果中与付费差异,探讨国家医疗保障疾病诊断相关分组(China Healthcare Security Diagnosis Related Groups, CHS-DRG)医保支付的局限性,为完善CHS-DRG分组方案提供参考。[方法]以新疆某DRG绩效平台2020年1月至2022年1月,使用CHS-DRG分组方案测算的数据为分析基础,将涉及不同范围手术的3个DRG病组(IC29、KB19、KD19)的5689份付费信息,与涉及新技术使用的3个病组(NC1、IF3、LJ1)的13,196份付费信息划为模型组和对照组,分析影响付费的因素与病组盈亏,并提出解决方案。[结果]不同手术范围模型组平均费用是对照组的1.45倍,患者年龄、性别、平均住院日对付费影响的差异无统计学意义(P>0.05),31天再入院计划差异有统计学意义(P<0.05);新技术使用情况的模型组平均费用是对照组的1.25倍,患者年龄、性别、31天再入院计划间差异无统计学意义(P>0.05),平均住院日差异有统计学意义(P<0.05)。89.12%的单侧病例和64.43%未使用新技术病例均为盈余病组,98.72%的双侧手术病例和89.61%使用了新技术病例均为亏损病组,二者对病组盈亏的影响有较强的相关性。[结论]支付方式革新对业务创新的影响有负面效应,可通过维护代码分类添加分组规则、引入评估机制确定补偿范围丰富分组机制。Objective To analyze the differences between new diagnosis and treatment technology, surgical cases in different ranges and payment in the China Healthcare Security Diagnosis Related Groups, CHS-DRG,to explore the limitations of CHS-DRG medical insurance payment, so as to provide reference for improving the CHS-DRG classification scheme.Methods Based on the data measured by CHS-DRG classification scheme in a DRG performance platform in Xinjiang from January 2020 to January 2022,5689 pieces of payment information of three DRG disease groups involving different ranges of surgery(IC29,KB19,KD19)were model group, and 13196 pieces of payment information of three disease groups involving the use of new technology(NC1,IF3,LJ1)were control group, to analyze the factors that affect payment and the profit and loss of the disease group and propose solutions.Results The average cost of patients in the model group with different ranges of surgery was 1.45 times that of the control group. There was no statistical significance for patients’ age, gender and average days in hospital on payment difference(P>0.05),and there was statistical significance for the difference of 31-day readmission plan(P<0.05). The average cost of the model group with the use of new technology was 1.25 times that of the control group. There was no statistical significance for the difference of patients’ age, gender and 31-day readmission plan(P>0.05),and there was statistical significance for the difference of average days in hospital(P<0.05).89.12% of unilateral surgery cases and 64.43% of cases without new technology were surplus disease group, and 98.72% of bilateral surgery cases and 89.61% of cases with new technology were deficit disease group. Both of them had a strong correlation on the profit and loss of the disease group.Conclusions The impact of payment innovation on business innovation has a negative effect. Enriching mechanisms of classification can be realized by maintaining the classification of code, adding rules of classification an

关 键 词：疾病及诊断相关组 医保支付 局限性 

分 类 号：R194[医药卫生—卫生事业管理]