按病种分值付费下妇科医保超费及精细化管理的研究  

Research on Overpayment and Refined Management in Gynecological Medical Insurance under the Diagnosis-Intervention Packet Payment System

作　　者：钟碧霞 蔡进 刘敬[1] Zhong Bixia;Cai Jin;Liu Jing(Guangzhou First People's Hospital,Guangzhou 510180,Guangdong Province,China)

机构地区：[1]广州市第一人民医院,广东省广州市510180

出　　处：《中国病案》2025年第1期17-20,共4页Chinese Medical Record

基　　金：广州市第一人民医院红棉计划项目(KY14040001)。

摘　　要：目的本研究旨在分析广州市某三甲医院妇科2023年DIP付费运营数据,以评估其医保运行状况,为医保控费和医院管理策略提供科学依据。方法收集2023年1月1日-2023年12月31日期间,该医院妇科DIP出院患者的1834例数据,运用二八法则、波士顿矩阵等方法,分析病种超费、构成分布、费用差异及诊断编码一致性。结果发现D25(子宫平滑肌瘤)等9个病种超费严重,占82.61%。优势病种为“为肿瘤化学治疗疗程:静脉输液港植入术”,需重点关注病种8个,劣势病种2个,发展潜力病种5个。不同治疗组在费用及住院时间上存在差异(P<0.05),医师1组表现最优。医师与编码员在主要诊断ICD-10编码上的一致率较低,仅为46.95%。结论该医院妇科DIP运营存在优化空间,建议聚焦超费病种,提升CMI,优化DIP临床路径,加强医师编码准确性,以强化医保控费和提升管理水平。Objectives This study aims to analyze the DIP Payment data of the gynecology department in a tertiary hospital in Guangzhou in 2023 to evaluate its medical insurance operation status and provide a scientific basis for medical insurance cost control and hospital management strategies. Methods A total of 1834 cases of DIP discharge data from gynecological patients in the hospital were collected between January 1, 2023, and December 31, 2023. The Pareto Principle, Boston matrix and other methods were used to analyze the loss of disease types,composition distribution, cost differences, and diagnostic coding consistency. Results It was found that nine types of diseases, including D25(uterine leiomyoma), had serious overpayments, accounting for 82.61%. The dominant disease type was "tumor chemotherapy course: intravenous infusion port implantation". There were eight key disease types requiring attention, two inferior disease types, and five disease types with development potential.Different treatment groups showed differences in cost and length of hospital stay(P<0.05), with Physician Group 1performing the best. The consistency rate between physicians and coders in ICD-10 coding was low, only 46.95%.Conclusions There is room for optimization in the gynecology DIP operation of the hospital. It is suggested to focus on the losing disease types, improve CMI, optimize DIP clinical pathways, and strengthen the accuracy of physician coding, in order to strengthen medical insurance cost control and improve management level.

关 键 词：按病种分值付费 妇科 医保管理 

分 类 号：R197.3[医药卫生—卫生事业管理]