DRG付费下医生异化行为监管的实践及思考  

Practice and Reflection on the Supervision of Doctor Alienated Behaviors under DRG Payment

作　　者：林振威 吴风琴[1] 程斌[1] 许晨虹 虞丽娟[1] 陈洁[1,2] LIN Zhenwei;WU Fengqin;CHENG Bin;XU Chenhong;YU Lijuan;CHEN Jie(Zhejiang Cancer Hospital,Hangzhou Zhejiang 310022,China;不详)

机构地区：[1]浙江省肿瘤医院,浙江杭州310022 [2]浙江省省级医院管理中心,浙江杭州310002

出　　处：《卫生经济研究》2024年第11期36-39,共4页

基　　金：2022年浙江省卫生健康科技计划(2022RC117,2022KY141);2022年浙江省医学会临床医学科研专项资金项目“‘便民医保’服务平台的开发”(2022ZYC-Z14);浙江省肿瘤医院2023年软科学研究专项培育基金立项项目“DRGs改革下基于临床路径的医保控费与医疗质量管理协同效果评估——以JB25组为例”(SSR2023B1)。

摘　　要：目的:探讨DRG付费下医生异化行为的监管策略,为医保部门加强监管提供参考。方法:分析DRG付费下医生异化行为的典型表现和原因,以样本医院为例,总结医院加强医生异化行为监管的做法和成效。结果:与2020年相比,2023年样本医院被扣减病例数减少215例,扣款金额减少338.57万元,15日内再入院病例从567例减少到208例。结论:DRG付费下,医院应构建全方位监管体系,关联资源消耗,加强智能审核,确定DRG监管靶点,进行精准管控,完善绩效考核方案,减少医生异化行为,促进医院高质量发展。Objective To explore supervision strategies for doctor alienated behaviors under DRG payment,and to provide reference for medical insurance departments to strengthen supervision.Methods The typical manifestations and reasons for doctor alienated behaviors under DRG payment were analyzed.Taking the sample hospital as an example,the practices and effectiveness of the hospital in strengthening the supervision of doctor alienated behaviors were summarized.Results Compared with 2020,the number of cases identified as violating regulations in the sample hospital in 2023 decreased by 215,the deducted amount decreased by 3.3857 million yuan,and the number of readmission cases within 15 days decreased from 567 to 208.Conclusion Under DRG payment,hospitals should establish a comprehensive supervision system,link resource consumption,strengthen intelligent auditing,determine DRG supervision targets,carry out precise control,improve performance evaluation plans,reduce doctor alienated behaviors,and promote high-quality development of hospitals.

关 键 词：DRG付费 异化行为 医保基金监管 

分 类 号：R19[医药卫生—卫生事业管理]