DRG低倍率病例特征、形成原因和政策优化  

Characteristics,Formation Causes and Policy Optimization of Low-ratio Cases in DRG

作　　者：潘雪冬 彭美华[2] 钟艳红 杨松[1] 顾强 李希 李悦 肖远会 PAN Xuedong;PENG Meihua;ZHONG Yanhong;YANG Song;GU Qiang;LI Xi;LI Yue;XIAO Yuanhui(The Third Affiliated Hospital of Chengdu Medical College,Pidu District People's Hospital,Chengdu Sichuan 611730,China;不详)

机构地区：[1]成都医学院第三附属医院·成都市郫都区人民医院,四川成都611730 [2]成都中医药大学管理学院,四川成都611137

出　　处：《卫生经济研究》2025年第2期59-63,共5页

基　　金：四川省纪检监察课题“医保基金监管‘行纪衔接’困境与对策研究”(SCJ220202)。

摘　　要：目的:分析低倍率病例特征,探究低倍率病例形成原因,提出规范医疗行为、优化支付政策的建议。方法:以M市为研究场域,获取159 065例低倍率病例信息,采用特征价格模型,分析低倍率病例的基本特征以及对医疗费用的影响。结果:疾病特征、费用特征、个体特征、分布特征、行为特征均对低倍率病例的医疗费用产生显著正向影响;低标准入院、不规范医疗行为、诊断和编码升级、分组与支付缺陷是低倍率病例的主要形成原因。结论:为减少不合理低倍率病例,应优化监管规则、完善考核机制、强化院内质控、完善分组与支付机制。Objective To analyze the characteristics of low-ratio cases,explore the reasons for the formation of low-ratio cases,and to put forward suggestions for standardizing medical behavior and optimizing payment policies.Methods Taking M city as the research field,the information on 159 065 low-ratio cases were obtained.Using the characteristic price model,the basic characteristics of low-ratio cases and their impact on medical costs were analyzed.Results Disease characteristics,cost characteristics,individual characteristics,distributional characteristics,and behavioral characteristics all had a significant positive impact on the medical costs of low-ratio cases.Substandard admissions,unstandardized medical behavior,diagnostic and coding upgrades,and grouping and payment deficiencies were the main reasons for the formation of low-ratio cases.Conclusion In order to reduce unreasonable low-ratio cases,it is necessary to optimize regulatory rules,improve assessment mechanisms,strengthen internal control within the hospital,and improve grouping and payment mechanisms.

关 键 词：低倍率病例 医疗行为 特征价格模型 

分 类 号：R197[医药卫生—卫生事业管理]