DRG支付下胃癌手术患者住院费用医保结余影响因素分析  

Analysis of factors influencing the medical insurance balance of hospitalization expenses for gastric cancer surgery patients under DRG payment

作　　者：傅杨杨 朱怀军[1] 卞晓洁[1] 高延庆 张庆红[3] 陶亮[3] 管文贤[3] Fu Yangyang;Zhu Huaijun;Bian Xiaojie;Gao Yanqing;Zhang Qinghong;Tao Liang;Guan Wenxian(FU Yangyang is currently Master′s Students in the School of Basic Medicine and Clinical Pharmacy,China Pharmaceutical University;Department of Medical Insurance Centre,Nanjing Drum Tower Hospital,Affiliated Hospital of Medical School,Nanjing University,Nanjing 210008,China;Department of General Surgery,Nanjing Drum Tower Hospital,Affiliated Hospital of Medical School,Nanjing University,Nanjing 210008,China)

机构地区：[1]南京大学医学院附属鼓楼医院药学部,南京210008 [2]南京大学医学院附属鼓楼医院医保中心,南京210008 [3]南京大学医学院附属鼓楼医院普外科,南京210008

出　　处：《中华医院管理杂志》2023年第5期326-331,共6页Chinese Journal of Hospital Administration

基　　金：江苏省研究生科研与实践创新计划项目(SJCX23_0230);南京市医疗保险研究会基础课题(NJYB2022JC006);南京大学中国医院改革发展研究院面上课题(NDYG2022015);南京大学中国医院改革发展研究院培育课题(NDYG2022051)。

摘　　要：目的分析疾病诊断相关分组(DRG)支付下胃癌手术患者住院费用医保结余的影响因素,为推动公立医院DRG支付改革,合理控制住院费用提供参考。方法选取2022年1—7月某三级综合医院胃肠外科DRG入组胃癌手术患者作为研究对象,分别从某市医保结算系统和医院信息管理系统提取患者年龄、医保结余和住院费用及其构成等指标信息。所有数据进行描述性分析,采用逐步多元线性回归分析患者医保结余影响因素,采用蒙特卡洛模拟方法对各影响因素的不同组合场景进行模拟,分析医保结余概率。结果共纳入205例患者,其中医保结余组117例,亏损组88例。两组患者的住院费用和医保结余差异有统计学意义(P<0.05)。医保专员干预、DRG正确入组、肠外营养制剂费用、抗感染药物费用、检查费用和耗材费用是患者医保结余的影响因素(P<0.05)。经蒙特卡洛模拟验证,使用不同抗感染用药方案或不同肠外营养制剂的患者,在医保专员干预且入组正确时,医保结余概率较大。结论医院通过医保专员干预,确保胃癌患者DRG入组正确,准确使用肠外营养制剂和抗感染药物,控制检查和耗材费用,可提升医保结余概率。未来医院应进一步推广药品耗材带量采购,减少不必要的检查,制定围手术期标准化营养干预及抗感染治疗路径,保证DRG入组准确性,优化临床诊疗路径,以提升医保基金使用效率,为患者提供高质量的医疗服务。Objective To analyze the influencing factors of the medical insurance balance of hospitalization expenses for gastric cancer surgery patients under DRG payment,for reference for promoting the reform of DRG payment in public hospitals and controlling hospitalization expenses reasonably.Methods The gastric cancer patients enrolled in the gastroenterology department of a tertiary comprehensive hospital from January to July 2022 were selected as the research subjects.The indicators such as patient age,medical insurance balance,hospitalization expenses and their composition were extracted from the hospital information management system and the medical insurance settlement system a certain city.Descriptive analysis was conducted for all data,and stepwise multiple linear regression was used to analyze the influencing factors of patients′medical insurance balance.Monte Carlo simulation method was used to simulate different combination scenarios of various influencing factors to analyze the probability of medical insurance balance.Results A total of 205 patients were contained,including 117 in the medical insurance balance group and 88 in the loss group.The difference in hospitalization expenses and medical insurance balance between the two groups of patients were statistically significant(P<0.05).The intervention of medical insurance specialists,correct DRG enrollment,parenteral nutrition preparation costs,anti infective drug costs,examination costs,and consumables costs were the influencing factors of patient medical insurance balance(P<0.05).Through Monte Carlo simulation verification,patients with different cost parenteral nutrition preparations,or different anti infective drug schemes had the higher probability of medical insurance balance in the scenario where the medical insurance commissioner intervenes and the DRG enrollment was correct.Conclusions The hospital adopted interventions from medical insurance specialists to ensure the correct DRG enrollment of patients,accurate use of parenteral nutrition and anti

关 键 词：医保结余 胃癌 住院费用 多元线性回归 蒙特卡洛模拟 疾病诊断相关分组 

分 类 号：R735.2[医药卫生—肿瘤]