DRG超支分担三段补偿法实践研究——以安阳市为例  

A Study of the Practice of Three-Stage Compensation Method Based on Share of DRG Overspending--Taking Anyang City as an Example

作　　者：吴洲 赵常青 石希庆 邢建国 

机构地区：[1]安阳市医疗保障局,安阳455000

出　　处：《中国医疗保险》2023年第10期86-90,共5页China Health Insurance

摘　　要：目的:统计2022年度安阳市对超出DRG支付标准(以下简称标准费用)的22493份病例进行超支分担清算(超支分担病例数占比为5.44%)的情况,分析三段补偿法的实际效果。方法:通过DRG付费系统调取病例数据,分析医疗费用低于等于标准费用1.5倍的病例、大于标准费用1.5倍的病例、不同权重病组、入组数较多病组、极高权重组、极低权重组病例基金补偿比和医院最终补偿比,观察DRG三段补偿法的效果及影响。结果:医疗费用大于标准费用1.5倍的病例的基金补偿比(DRG清算金额/按项目基金支付额)为80.81%,医院最终补偿比((个人负担费用+DRG最终清算金额)/总费用)为88.76%。不同权重、入组病例数较多、极高权重组、极低权重组超支病例的基金补偿比在75.85%到90.35%,医院最终补偿比在85.37%到93.89%。结论:通过三段补偿法对超出标准费用的病例进行超支分担清算,可在一定程度上保障医疗机构超支病组保本运行,有利于保障DRG支付方式改革的顺利推行。Objective:The paper analyzes the effect of three-stage compensation method,with DRG overspending settlement of 22493 cases(5.44%)beyond DRG payment standard in Anyang City in 2022.Methods:We collected data of cases from the DRG payment system,analyze cases whose medical expenses are less than or equal to 1.5 times the standard cost,cases whose medical expenses are more than 1.5 times the standard cost,groups with different weight,groups with more enrollments,groups with extremely high weight,groups with extremely low weight fund compensation ratio,and hospitals’final compensation ratio,and observe the impact of the DRG three-stage compensation method.Results:The fund compensation ratio for cases whose medical expenses exceed 1.5 times the standard cost was 80.81%,and the hospitals’final compensation ratio was 88.76%.The fund compensation ratio of overbudget cases with different weights,larger number of enrolled cases,groups with extremely high weight and extremely low weight ranged from 75.85%to 90.35%,and the final compensation ratio of hospitals ranged from 85.37%to 93.89%.Conclusion:The three-stage compensation method for the overspending settlement of cases beyond the standard cost can to some extent guarantee the operation of hospitals overspending cases and smooth implementation of DRG payment standard.

关 键 词：DRG付费 超支分担 三段补偿法 基金补偿比 医院最终补偿比 

分 类 号：F840.684[经济管理—保险] C913.7[社会学]