DRG付费下医疗机构违规行为分析及监管策略  

Problems and Countermeasures in the Supervision of Medical Insurance Funds under DRG Payment

作　　者：张磊[1] 乔岩 李会明[1] 荣洁 王蓬[1] ZHANG Lei;QIAO Yan;LI Huiming;RONG Jie;WANG Peng(Tianjin Union Medical Center,Medical Insurance Administration Office,Tianjin,300121,China;不详)

机构地区：[1]天津市人民医院医疗保险办公室,天津300121 [2]天津市人民医院感染控制处,天津300121

出　　处：《中国社会医学杂志》2025年第2期145-148,共4页Chinese Journal of Social Medicine

基　　金：天津市医院协会医院管理研究项目(2017003);天津市人民医院基金项目(2023YJHL040)。

摘　　要：疾病诊断相关分组(diagnosis related groups,DRG)付费作为一种精细化的医疗付费方式,已经在我国逐渐得到推行和应用。然而,DRG付费也给医疗机构和医保基金管理部门带来了一系列监管难点。通过分析天津市某三甲综合医院DRG付费下存在的违规行为,明确医保拒付原因,提出了相应的监管建议。2021-2023年审核拒付239例,拒付最多的类型是转嫁费用,其次是分解住院、高靠分组;违规病例主要集中在MDCR组,最多的DRG组是RE13,其次是RG13。分析成因主要是DRG分组数据来源于病案首页、医保基金监管体系薄弱、医疗机构运营压力、患者信息不对称和低自觉性。建议监管部门应明确违规情形,强化监管力度;提高医疗机构的法律意识,完善DRG付费下的医院管理,促进市场机制的运行,建立“量价挂钩”的付费调节机制;加强对患者权利的保护,发挥社会监督作用。As a refined form of medical payment,the diagnosis related groups(DRG)payment system has been gradually implemented and applied in China.However,it has also brought a series of regulatory difficulties to medical institutions and medical insurance fund management departments.This paper analyzed the violations of DRG payment in a tertiary comprehensive hospital in Tianjin,clarified the reasons for medical insurance refusal,and proposed corresponding regulatory recommendations.From 2021 to 2023,239 cases of refusal to pay were reviewed,with the most common type of refusal being transfer fees,followed by decomposed hospitalization and high dependency grou-ping;The main concentration of cases of violations was in the MDCR group,with the highest DRG group being RE13,followed by RG13.The main reasons for the analysis were that the DRG grouping data from the medical record homepage,the weak regulatory system of the medical insurance fund,operational pressure on medical institutions,patient information asymmetry,and low self-awareness.Regulatory authorities should clarify violations,strengthen regulatory efforts,enhance the legal awareness of medical institutions,improve operational management under DRG payment,promote the operation of market mechanisms,establish a"quantity price linked"payment adjustment mechanism,play a social supervision role,and strengthen the protection of patient rights.

关 键 词：DRG付费 医疗保险 违规行为 基金监管 

分 类 号：R197.323[医药卫生—卫生事业管理]