甘肃省某三级医院DRGs支付方式改革实践探索

Reform on diagnosis-related groups(DRGs)payment mode in a tertiary hospital in Gansu Province

王莉霞 ¹王燕 ¹党文伟 ¹王晨阳 ¹钟金森¹

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作者信息

1. 741000 甘肃省天水市,天水市第一人民医院
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摘要

目的探讨公立医院实施医保精细化管理方案,以应对DRGs支付方式改革的顺利进行.方法自2023年起,医院实施了一系列医保管理措施,包括:设立"医保专员"管理制度,开展PDCA循环的医保精细化管理与培训,严格控制费用与监管基金;持续提升医疗技术水平,规范诊疗行为,优化病种结构,建立基于DRGs的医保支付临床路径;加强编码员队伍建设,提升数据质量;开发病案管理信息化辅助工具,引入院内智能监管系统;利用PDCA循环持续改进病案质量;开展基于DRGs的绩效考核与成本核算等.结果从DRG入组情况、服务能力、服务效率、费用控制、医疗安全、医保监管6个维度分析实施效果,结果显示:未入组、歧义组和入组错误病例占比下降;出院患者平均住院日、均次费用、药占比和耗占比均显著下降;低风险病死率和高倍率人次占比下降;DRG组数增加,治愈、好转率和总权重上升.结论 DRGs精细化管理的实施,增强了医护人员的全员参与意识,提升了病案首页和医保结算清单的数据质量,提高了医疗技术与服务能力,降低了住院费用,合理分配了医疗资源.然而,CMI值和三、四级手术占比略有下降,原因在于科室发展不均衡、本地支付政策欠合理、患者选择范围扩大、高值耗材费用昂贵以及疫情影响病种结构等.实践结果为医院顺利应对DRGs支付方式改革、实现高质量医疗服务提供了依据.

Abstract

Objective To explore strategies for public hospitals to implement refined management plan on healthcare insurance to support the reform on the diagnosis-related groups(DRGs)payment mode.Methods A series of healthcare insurance management policies have been implemented in our hospital since 2023,including a management system for medical insurance commissioners,PDCA cycles for refined management and training,rigorously regulated costs and funds,continually advanced medical technology,standardized medical procedures,and optimized case mix.DRGs-based payment pathways were established to improve data quality.IT tools were used for medical record management and in-house intelligent monitoring system was used to facilitate DRGs-oriented performance assessment and cost accounting.Results Analysis using six dimensions including DRGs enrollment,service capacity,service efficiency,cost control,medical safety,and medical insurance supervision revealed notable improvements,including reduced proportions of ungrouped and misclassified cases,shorter average lengths of stay and lower average costs per discharge,decreased mortality rates and proportions of high-risk patients,increased number of DRGs groups,and escalated cure/improvement rates and total weights.Conclusion The adoption of refined DRGs management has raised healthcare staff engagement,upgraded medical record and insurance data quality,advanced local medical technology and service capacity,cut hospitalization costs,and led to a more efficient allocation of medical resources.However,the Case Mix Index(CMI)and the proportion of levels 3 and 4 surgeries marginally decreased due to departmental disparities,sub-optimal local payment policies,expanded patient selection,high costs of high-value consumables,and pandemic-related shifts in case mix.These findings offer a foundation for efficiently adapting to payment reforms and ensuring high-quality medical services.

关键词

DRGs支付/医保质量管理体系/医保结算清单/PDCA质量管理

Key words

DRGs payment/Medical insurance quality management system/Medical insurance settlement list/PDCA quality management

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出版年

2024

中国医疗管理科学

ISSN：

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