省内异地就医按疾病诊断相关分组入组病例的住院费用分析  

Analysis of hospitalization costs for diagnosis related group enrolled cases seeking medical treatment in different regions within the province

作　　者：苏会璇[1] 叶沛仪 饶苑平 SU Huixuan;YE Peiyi;RAO Yuanping(Department of Medical Insurance Management,Beihai People's Hospital,Guangxi Zhuang Autonomous Region,Beihai536000,China;Department of Network Finance,Southern Fund Management Co.,Ltd.,Guangdong Province,Shenzhen518000,China)

机构地区：[1]广西壮族自治区北海市人民医院医疗保险管理科,广西北海536000 [2]广东省南方基金管理股份有限公司网络金融部,广东深圳518000

出　　处：《中国当代医药》2024年第34期91-95,共5页China Modern Medicine

摘　　要：目的探讨按疾病诊断相关分组(DRG)付费下省内异地医保与本地医保住院费用的异同。方法收集2022年4月至2023年10月北海市人民医院结算的省内异地医保4610例病例数据和本地医保住院69619例病例数据资料进行回顾性分析,排除不符合DRG支付规则的住院病例(职工生育及生育并发症、急诊留观、家庭病床、离休人员、诊断新型冠状病毒感染和住院天数>61 d)和不能正常入组DRG的歧义组、空白组。结果省内异地医保的DRG病种覆盖面和病例组合指数低于本地医保,个人负担和自费项目费用及其占比均高于本地医保,例均药品费用低于本地医保,差异均有统计学意义(P<0.05)。省内异地医保恶性增生性疾患的靶向及免疫治疗、化学治疗和其他治疗的例均总住院费用高于本地医保,差异有统计学意义(P<0.05)。结论DRG医保支付在控制省内异地医保总住院费用和本地医保有相同的效果,政策培训及解读仍需继续深入临床。Objective To explore the differences and similarities of hospitalization costs between provincial remote medical insurance and local medical insurance under diagnosis related group(DRG)payment.Methods The data of 4610 cases of remote medical insurance and 69619 cases of local medical insurance in Beihai People's Hospital from April 2022 to October 2023 were collected and analyzed retrospectively.Inpatients who did not meet the DRG payment rules(maternity and birth complications of employees,emergency observation,family beds,retired personnel,diagnosis of novel coronavirus infection and hospital stay>61 days)and ambiguous and blank groups that could not be normally enrolled in DRG were excluded.Results The DRG disease coverage and case mix index of remote medical insurance were lower than that of local medical insurance,the individual burden and out-of-pocket project cost and their proportion were higher than that of local medical insurance,and the per case drug cost was lower than that of local medical insurance,with statistical significances(P<0.05).The total hospital expenses of targeted immunotherapy,chemotherapy and other treatments for malignant proliferative diseases in remote medical insurance were higher than those in local medical insurance,and the differences were statistically significant(P<0.05).Conclusion DRG medical insurance payment has the same effect on controlling the total hospitalization cost of remote medical insurance and local medical insurance in the province,and further clinical training and interpretation of the policy need to be carried out.

关 键 词：医保住院 省内异地 按疾病诊断相关分组 住院费用 

分 类 号：F840.684[经济管理—保险] C913.7[社会学]