DRG付费下基础病组优化成效评估——以山东省某三级综合医院为例  

Evaluation on the Effectiveness of Optimizing the Basic Disease Groups Under the Background of DRG Payment——Taking a Tertiary Comprehensive Hospital in Shandong Province as an Example

作　　者：孟凡舜 王海龙 靳伟 刘卫东[3] 管延鹏 姜良美[3] 

机构地区：[1]山东大学齐鲁医学院公共卫生学院卫生管理与政策研究中心,济南250012 [2]国家卫生健康委员会卫生经济与政策研究重点实验室(山东大学),济南250012 [3]临沂市人民医院,临沂276000

出　　处：《中国医疗保险》2024年第4期85-90,共6页China Health Insurance

基　　金：临沂市重点研发计划(医学类)“医保DRG付费下三级综合医院的管理策略与效果评价研究”(2022YX0094)。

摘　　要：目的:分析比较山东省某三级综合医院在实施“同病同价”政策前后相关病例收治变化,评估“同病同价”政策的实施效果。方法:获取山东省某三级综合医院2023年纳入DRG付费基础病组的病例医保结算清单信息、DRG入组等信息,采用描述性统计分析、非参数检验等统计方法对政策实施前后的数据进行统计分析。结果:政策实施前后,样本医院收治基础病组的例数和占比均明显下降,基础病组医疗费用管控效果明显,促进了医保基金使用效率的提升和患者费用负担的减轻;通过基础病组分级诊疗,医院病种结构也得以优化提升。结论:基础病组支付政策在推动三级医院落实分级诊疗、降低病种成本、夯实功能定位等方面具有积极的意义。Objective:The paper analyzes and compares the changes in the admission of relevant cases before and after the implementation of the"same disease and same price"policy in a tertiary comprehensive hospital in Shandong Province,and evaluates the effect of the policy in tertiary comprehensive hospitals.Methods:We obtain the medical insurance settlement list information and DRG enrollment information of cases included in the DRG basic disease group of a tertiary comprehensive hospital in Shandong Province in 2023,and uses descriptive statistical analysis,non-parametric testing and other statistical methods to statistically analyze the data before and after policy implementation.Results:Before and after the implementation of the policy,the number and proportion of cases admitted to the basic disease group in the sample hospitals significantly decreased,and the medical cost management effect of the basic disease group was significant,promoting the improvement of the efficiency of medical insurance fund utilization and the reduction of patient cost burden.At the same time,the hierarchical diagnosis and treatment of basic disease groups has effectively optimized the hospital's disease category structure.Conclusion:The basic disease group payment policy has positive significance in promoting the implementation of hierarchical diagnosis and treatment,reducing disease costs,and strengthening functional positioning in tertiary hospitals.

关 键 词：DRG付费 基础病组 同病同价 分级诊疗 

分 类 号：F840.684[经济管理—保险] C913.7[社会学]