基于“国考”及DRG付费的三级医院手术病例质效研究  

Analysis of Medical Insurance DRG Balance for Surgical Cases in a Tertiary General Hospital based on Healthcare Quality Performance Indicators of National Tertiary Public Hospitals

作　　者：刘成[1,2] 李梦滢 LIU Cheng;LI Mengying(Beijing Tsinghua Changgung Hospital/School of Clinical Medicine,Tsinghua University,Beijing 102218,China;不详)

机构地区：[1]清华大学附属北京清华长庚医院/清华大学临床医学院,北京102218 [2]清华大学医院管理研究院,北京100084

出　　处：《卫生经济研究》2025年第2期85-89,共5页

基　　金：国家卫生健康委医院管理研究所2024年医疗质量(询证)管理研究项目“基于CHS-DRG病种的手术高值耗材用耗模式及超支原因探究”(YLZLXZ24G087)。

摘　　要：目的:分析公立医院手术病例医保DRG结余情况,为提高医院运营管理效率提供决策依据。方法:以北京市某三级综合医院13 127例手术病例为样本,基于“国考”医疗质量指标,分析DRG实际结余率,以及医疗质量与DRG结余率之间关系。结果:样本医院手术病例的DRG结余率为0.281 1,其中四级手术和微创手术的DRG结余率较低,CMI值与DRG结余率正相关;非集采手术病例DRG结余率为0.240 8,结余主要来自优势专科和病种。结论:医院要分层分类制定科室精细化管理策略,促进学科发展和内涵建设;加强临床路径管理,改善医疗服务供给质量和效率;积极参与医保部门的协商谈判,创新多元补偿机制,实现DRG付费下兼顾医疗质量提升和经济效益改善的高质量发展。Objective To investigate the relationship between healthcare quality performance indicators and DRG economic profits in surgical cases in a tertiary public general hospital,and to provide a reference for hospitals to achieve synergy and win-win results in both aspects.Methods13127 surgical patients who participated in CHS-DRG payment at a tertiary public general hospital in Beijing from March 2022 to December2023 were sampled.The proportion of fourth-level surgery,minimally invasive surgery and CMI were representative indicators from performance evaluation on national tertiary public hospitals,and time consumption index,drug and consumables consumption index were representative indicators of DRG payment reform.The actual DRG balance rate and the relationship between healthcare quality and DRG balance rate in different departments and diseases were analyzed.Results The DRG balance rate of surgical cases was 0.2811,with lower DRG balance rates for fourthlevel surgery and minimally invasive surgery compared to other surgeries.CMI was positively correlated with DRG balance rate.After excluding the factor of centralized volume-based procurement high-value medical consumables,the balance rate of surgical cases was 0.240 8,and the DRG settlement of fourth-level surgery became a loss,while the DRG settlement of minimally invasive surgery remained profitable.According to the analysis results at the department and disease level of the four-level surgical samples after excluding the cases of centralized volume-based procurement policies,DRG profits mainly came from advantageous specialties and diseases.Conclusion It is necessary to develop refined management strategies for hierarchical classification of departments,strengthen clinical pathway management,improve the quality and efficiency of medical service supply,actively participate in negotiations with the medical insurance administrative department,innovate diverse payment methods,and promote high-quality development of public hospitals under DRG payment.

关 键 词：三级公立医院 医疗质量指标 医保DRG结余 手术病例 

分 类 号：R197[医药卫生—卫生事业管理]